Dealing with insurance & Medicare

Dealing with Insurance and Medicare for sleep apnea patients can be frustrating. Changes is procedures and rules occur often; therefore the information on this page may not be completely up-to-date.

Sample CPAP Prescription is a separate Wiki that you may consult to understand what information may be required by suppliers in the form of a prescription.

Coverage under Insurance and Medicare

Most health care insurance and Medicare programs cover the cost of CPAP. This includes normal CPAP replacement supplies. Common replacement schedules are:

• Disposable filters: 2 new filters every month
• Non-disposable filters: Every 6 months
• Full face mask/cushion: Every 3 months
• Nasal mask/cushion: Every 3 months
• Pillow system/cushion: Every 3 months
• Headgear: Every 6 months
• Tubing: Every 3 months
• Chin strap: Every 6 months
• Humidifier chamber: Every 6 months
• CPAP Mask: 90 days
• CPAP Headgear: 180 days
• CPAP Tubing: 30 days
• Disposable Filter: 30 days
• CPAP Chinstrap: 180 days
• Full Face Mask: 90 days
• Full Face Cushion: 30 days
• Nasal Cushion: 30 days
• Replacement Pillow: 30 days
• Non-disposable Filters: 180 days
• Oral Interface: 90 days
• CPAP Machine: varies (average lifespan of a CPAP is approximately five years)

Tips

If using Medicare, you must verify that your DME supplier is a Medicare Participating Provider that accepts assignment. Many providers claim to "accept Medicare", but if they are not a "Participating Provider", they may charge fees and costs in addition to your coverage. Check here for participating providers in your area, or to verify your DME is a participating provider Medicare Provider Directory Search

Be sure to read the Wiki, [With A DME] for more details on Medicare and insurance coverage and issues with DMEs that may not be representing your interests or might be asking for sleep tests that are not required.

Insurance and Medicare FAQs

(Frequently Asked Questions)

My insurance company paid for my sleep test. Will they also pay for the continuous positive airway pressure (CPAP) equipment?

Insurance payors have different coverage guidelines, depending on the diagnosis and the contract with the durable medical equipment (DME) company. Contact your payor's customer service department listed on the back of your insurance card to identify what is allowed and what the copay may be. It is not uncommon that your insurance company may require supporting medical records to make a coverage determination. Your DME company can assist you with this process.

My mask is getting worn. How can I determine if my insurance will pay for a replacement mask?

Contact your DME company. They should have a record of your health insurance carrier's replacement schedule, but if they don't, you can contact the insurance company directly. Ask to speak with a representative who can give you an explanation of your durable medical equipment replacements. When you have that representative on the line, ask how often you are eligible for CPAP accessory replacements, specifically your mask system.

New positive airway pressure (PAP) technologies are entering the market, and I am interested in trying a new product. Will my insurance pay for another PAP device?

Many payors will consider replacement of a PAP device after five years of use. However, if your condition has changed, resulting in a need for a different pressure or features that your current machine does not have, your health insurance carrier will often upgrade the equipment at an earlier date. The insurance company may require a "letter of medical necessity" that a new device is required. Contact your DME and your physician about a letter of medical necessity.

My DME provider put me on an autotitrating device for a short time to help determine the optimum CPAP pressure I should receive. I really liked the autoPAP. It was more comfortable than the CPAP device the DME set me up on. How can I convince my physician and insurance payor to allow the DME to give me the autoPAP back?

Due to the additional features of APAP devices, they are more expensive. Some payors will allow the patient to pay the difference between the CPAP and the APAP device.

In some cases the insurance company can make a determination to pay for a higher cost machine if the physician can provide a letter of medical necessity. Contact your DME company or your insurance company regarding this issue.

How can I find the coverage information of my insurance plan?

Many health insurance companies provide a policy booklet to new enrollees. Others provide access to coverage polices through the company's Web site. If you get your health insurance through your employer, contact your Human Resources department for details. You can also contact your insurance company directly to obtain a copy of your benefits.

My physician prescribed a specific brand or type of CPAP device but when the home care company set me up, they delivered another unit. Are they all the same?

Specific CPAP devices may have been contracted between the homecare provider and your insurance company. "Formularies," much like prescription formularies, allow for generic substitution. However, if your physician wrote a prescription for a specific type of CPAP and was not contacted to ask if it could be "substituted," then you may have cause to insist upon the brand that the physician prescribed. In some cases, additional copays may exist.

My home care company contacted me to let me know that my mask should be replaced and I might have a copay. Is this normal behavior for the homecare company to contact me?

You are fortunate that the home care company is following up on your care. Different patients have different experiences with their equipment. Regular maintenance of your CPAP and mask are important to your overall therapy. A worn mask or dirty filters can effect your treatment and health. You may be responsible for a copay every time you replace a part of your CPAP equipment. You will probably need to contact your health insurance carrier for an explanation of your durable medical equipment benefits and replacement schedule.

Only one part of my mask needs replacing. Do I have to buy the entire mask or are there replacement pieces?

Replacement parts vary by mask types. Many masks have replaceable components. Contact your DME to discuss the replacement parts, out of pocket expenses, and delivery.

I am insured by the Veterans Administration (VA). They recently changed their contract with a new home medical equipment provider. The DME wants to pick up my CPAP and deliver another type. Do I have any say in what CPAP equipment I use?

One reason a CPAP may be exchanged for another model is because the CPAP unit is in a "rental" phase. The VA contracts directly with DME providers. Contracts are reviewed yearly. During the contract review phase, the VA may evaluate and choose an alternative DME provider. This new DME provider may have a different CPAP supplier than the previous DME company. If the CPAP is completely paid for, then you most likely will not have to change your device.

My insurance company sent me an Explanation of Benefits (EOB) after I had received my CPAP device. What should I do with this form?

The EOB provides you documentation of billed services, reimbursement by the insurance company, and your out-of-pocket expenses. Be sure to pay close attention to what the company billed your insurance company and what services were provided. It is a good idea to keep all of your EOBs on file for your future reference. Be sure to cross-reference this EOB to any bill you may receive from the DME company.

My DME sent me a notice that my CPAP is a "Capped Rental". What does this mean?

Medicare will pay a monthly rental fee for a period not to exceed 13 months. Original Medicare covers 80% of the cost of the monthly rental fee and the beneficiary or Advantage Plan will pay up to the remaining 20% coinsurance in accordance with policy terms. After the rental term ownership of the equipment is transferred to the Medicare beneficiary. During the rental period, copays and deductibles may apply. After ownership of the equipment is transferred to the Medicare beneficiary, it is the beneficiary’s responsibility to arrange for any required equipment service or repair.

My spouse is on CPAP and we have Medicare as our insurance provider. I received a letter from the DME requesting that I complete a patient statement regarding compliance and use of the equipment. Why does the DME need this information?

In efforts to control unnecessary spending and identify fraud, Medicare now requires the DME provider to send this statement to the patient or caregiver. The patient or the immediate caregiver must sign the form. This form documents that the patient is using the medical equipment and allows the DME to bill and obtain reimbursement. Medicare will stop paying the DME company for this equipment if the patient or responsible party does not sign this statement.

I had a follow-up appointment with my doctor one month after I began my CPAP treatment. My doctor reviewed the data from the CPAP machine and told me that I needed another type of machine because this one wasn't keeping my airway open enough. Do I have to keep this machine even though it didn't work for me?

Your DME will let you know if the device will be replaced. In some cases, the CPAP device will be returned to the DME provider and another device will be provided. In other cases, your insurance provider may have already paid for the purchase of the CPAP. Contact your DME company and or your insurance company to review your options regarding the initial piece of equipment.

My DME provider referred to the "DMERC" when talking to me about what portion of my CPAP equipment would be covered. What does DMERC stand for?

DMERC stands for Durable Medical Equipment Regional Carrier. The DMERC is a third-party payor responsible for paying your Medicare Part B allowables.

What does "In Network" mean?

Healthcare providers (hospitals, sleep labs, doctors, DMEs, etc.) review insurance contracts to determine if they want to sign the payment agreement. Those providers signing the contract are referred to as "In Network Providers." The healthcare providers have agreed with your insurance company in advance to what they will be paid for services. Your insurance carrier may require you to use an "In Network" healthcare provider. If you choose a healthcare provider that is "out of network," then you may have additional out of pocket expenses to pay.

What is a deductible?

A deductible is the dollar amount that your insurance company requires you to pay for care before they will begin to pay for your billed health care services. This amount varies by insurer and is usually paid annually.

What is a copay?

A copay is a percentage or set rate the insurance company requires the patient to pay towards their medical care at each purchase or visit.

What is the difference between Medicare Part A and Part B?

Medicare Part A provides coverage for hospitalization and some outpatient services. Medicare Part B provides coverage for most outpatient services including medical equipment, pharmaceuticals, physician visits, and home health care.

How do I dispute a decision made by my insurance company?

Most insurance companies have an appeal or grievance process outlined in their policy manual. Many EOB forms provide this type of information on the back of the form. You can also call your insurance company's customer service department to request these instructions.

Who do I contact for Medicare questions?

Medicare has an ombudsman assigned to each state. You can contact your state Medicare office to inquire about how to contact this individual or your regional Medicare office.

Insurance and Medicare Billing Codes

CPAP/BiPAP MACHINE INSURANCE (HCPCS) CODES:

E0601 Continuous airway pressure (CPAP/APAP) device
E0470 Respiratory assist device, bi-level pressure (BiPAP) capability, WITHOUT backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
E0471 Respiratory assist device, bi-level pressure (BiPAP) capability, WITH backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
E0472 Respiratory assist device, bi-level pressure (BiPAP) capability, WITH backup rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device)
E0561 Humidifier, non-heated, used with positive airway pressure (CPAP/BiPAP/APAP) device
E0562 Humidifier, heated, used with positive airway pressure (CPAP/BiPAP/APAP) device

CPAP/BiPAP MASK INSURANCE (HCPCS) CODES:

A7030 Full Face Mask used with Positive Airway Pressure (CPAP/BiPAP/APAP) Device
A7034 Nasal interface (mask or cannula type) used with positive airway pressure (CPAP/BiPAP/APAP) device , with or without headstrap
A7044 Oral interface used with positive airway pressure (CPAP/BiPAP/APAP) device
K0553 Combination oral/nasal mask, used with continuous positive airway pressure device

CPAP/BiPAP PART & ACCESSORY INSURANCE (HCPCS) CODES:

A7032 Replacement Cushion for Nasal or Full Face Mask
A7033 Replacement Pillows for Nasal Mask
A7035 Headgear used with positive airway pressure device
A7036 Chinstrap used with positive airway pressure device
A7037 Tubing used with positive airway pressure device
A7038 Filter, disposable, used with positive airway pressure device
A7039 Filter, non-disposable (reusable), used with positive airway presssure device
A7045 Exhalation port with or without swivel used with accessories for positive airway pressure devices
A7046 Water chamber for humidifier, used with positive airway pressure device
A9900 or E1399 Miscellaneous Durable Medical Equipment Items, Components and Accessories
K0554 Oral cushion for combination oral/nasal mask
K0555 Nasal pillows for combination oral/nasal mask

Buying Out-Of-Network With Insurance Coverage

This section is adapted from a post by member Jerry Sends Buying CPAP Out Of Network What I learned from my skirmish with the insurance "customer service "representatives:

• Don't take no for an answer if insurance refuses to pay or wants to pay at out of network rate, ask for a supervisor
• Ask for the supervisor of the supervisor if you aren't getting anywhere
• The CS lower level CS folks have little power, upper level, significant.
• You may have a representative from your employee group within the insurance CS chain, we did. A Very helpful person.
• You will have to jump through hoops, document the time & steps taken, do your due diligence & explain how frustrating the process has been.
• Insurance companies have the power to make reasonable exceptions if they know all the facts & about your medical complexities that put you at greater risk of landing in the hospital
• You can request a "Benefit Level Exception" to move equipment purchases/service from out of network to in network if there are extenuating circumstances such as no machines available locally or long wait lists.
• If denied, write an appeal letter stating extenuating circumstances & medical complexities. This is reviewed by a separate medical board.
• You can always submit for reimbursement even if they may deny, sometimes it slips through.
• Insurance companies really want to avoid

significant time/paperwork and/or a complaint to the state medical commissioners office. Be the squeaky wheel.

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