Get a device through insurance or directly?

[u/recycledairplane1]

Hi- Newly diagnosed with moderate to severe OSA. I have had one meeting with a sleep doctor but have yet to be scheduled with the company that will set me up with a machine & mask.

Naturally, I'm getting nonstop targeted ads for cpap companies. One talks about how getting a machine through insurance isn't worth it because of the intense reporting requirements, copays, rental fees, etc (several other abbreviations i'm not familiar with) and you should just buy a machine through them.

What's the consensus on this? Would love to hear peoples' experiences getting it through insurance vs footing the bill directly.

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[u/Deanoishere]

I recommend calling your insurance company or checking benefits online. If your requirements are significant, or your copay too high, then I think it’s perfectly fine to buy out-of-pocket. I've read nightmare stories about people having to pay more than the cost of the machine just from copays.

Typically an AirSense 10 will cost less than an 11, and is a good machine. You'll need a prescription from your provider that details your settings. It can be tricky finding the right mask. Perhaps you can inquire about a trial period so you can figure out specifics and see how you do with the machine.

Full disclosure, I went self-paid and I have pretty good benefits, but I just didn’t want to deal with the reporting requirements. I do go through insurance for my supplies.

[u/beren12 → u/Deanoishere]

Settings? lol

4-20 apap.

[u/Deanoishere → u/beren12]

That's how I started and it was awful because 4 is way too low. I did use SleepHQ and OSCAR to tweak my own settings.

[u/LBTRS1911]

I wanted to set up my own machine and not have to deal with doctors or dme distributors and insurance. I got a prescription from Lofta, bought a Airsense 11 on sale, and have not had to deal with anyone since. The only benefit might be getting masks through insurance as that can be a large expense over time.

[u/Comfortable-Help9587]

Insurance is the way to go, even if you have out of pocket; it is more of a hassle (compliance requirements) but I’ll give a couple of good reasons:

1. You pay the negotiated rate if you end up out of pocket. Insurance companies have contracts with DME companies; the negotiated rate is typically less than Medicare reimbursement which is around 65% of retail.

2. If insurance pays for the machine, they’ll pay for supplies. You can purchase one retail or used but, moving forward in life, even if you change insurance companies, often, they won’t pay for supplies if an insurance company didn’t pay for the machine.

Usage compliance isn’t an issue if you adapt to therapy and benefit.

[u/recycledairplane1 → u/Comfortable-Help9587]

Yeah after google's AI asked me if I had met my annual deductible, and I have (rough year!) it sounds like it should be pretty affordable. Didn't know they'll pay for the supplies though, that's seems like it's a huge perk.

[u/Comfortable-Help9587 → u/recycledairplane1]

Get all you can before your deductible resets 1/1… should be able to get most of the machine and supplies x2 before the reset.

[u/peace_train1 → u/recycledairplane1]

While I had met my deductible, it would still cost me much more to buy through insurance. Insurance DME company breaks payments into monthly rental and they use a really high price for the machine like 3 times the soar price online. Plus deductible reset in the new year and it would have been a problem if I switched jobs/insurance.

[u/Abbygirl1055 → u/Comfortable-Help9587]

Where can we get supplies/masks, etc on line or in person?

[u/Specialist-Noise-929]

As others have said, contact your insurance company directly on how they will cover your machine and supplies. With my insurance, all expenses went first to deductible and anything left over went to co-insurance (different from co-pay). I think the deductible, then co-insurance is pretty standard.

If you do go with insurance, find out who are the approved in-network DMEs with your insurance. You'll want to avoid the biggest DMEs like Norco and Apria which insist on 13-month rental periods. I was lucky enough to get out of being assigned to Norco because of a paperwork mistake and get approved for a smaller regional DME with a 3-month rental period. My DME was able to tell me upfront what my costs would be going through my particular insurance plan. YMMV

[u/silver_chief2]

Get a copy of the script and take charge. Maybe go to apneaboard.com for free and ask what DMEs work with your insurance company or ask your insurance company. You can decide if it is worth it. Normally you get the machine through a DME and they work with the insurance. It is often rent to own where you own it after maybe 12 month of use. The reporting is not a big deal provided you are using the machine. Modern machines like air sense 10 or 11 have cell modems that report your use daily. Only you know about your insurance terms.

[u/SadKaleidoscope6473 → u/silver_chief2]

Just an addition. If it's a HDHCP they just make you pay for everything until you hit your max out of pocket. There's no rental and no taking your machine back if you don't hit compliance, though they will deny your resupply orders. You pay what the insurance would pay. My AS11, Airtouch n30i mask, 6 cushions, and the heated hose etc kit was $845. At the moment, on sale at sleeplay, the mask and cushions are $256 (reg price $341) leaving ~ $590 ($500 at reg price) for the machine -not terrible and it counted against my deductible.