¿Por qué mi compañía de seguros no paga los suministros de CPAP que necesito?

Our patients get extremely frustrated when they contact us to order replacement supplies- at the usual 90 to 120 day intervals- but their health insurance company won’t pay. It’s especially hard because we’ve been saying- since the initial set-up- how important it is to regularly replace CPAP equipment, like the mask, cushions, filters and tubing.

Your CPAP’s accessory equipment is a lot like other frequently used health products, such as your toothbrush or a razor: it deteriorates, ceases to function optimally, and can become unsanitary. Just like you wouldn’t use the same toothbrush for months on end, it’s important to replace your CPAP equipment to make sure that your machine is as clean, effective, and comfortable as possible. There are three main reasons you should regularly replace your PAP equipment: 

1. Higiene. Los equipos de PAP, como los tubos y las mascarillas, pueden ensuciarse con el tiempo. Sustitúyalos con regularidad para mantener la higiene de la máquina. 
2. Eficacia. Es vital sustituir periódicamente su equipo para que funcione correctamente. Por ejemplo, a medida que envejecen, las mascarillas pueden agrietarse o estirarse, provocando irritaciones y fugas. 
3. Comodidad. Los equipos viejos, especialmente las mascarillas y los cojines, pueden irritar la cara y provocar falta de cumplimiento. 

Health insurance companies are supposed to cover the regular replacement of CPAP supplies, but increasingly, our patients are having issues getting approval for new supplies.

What gives?

In this short blog series, we’ll cover the top reasons why health insurance companies are denying regular 90-120 day replacement CPAP supply orders and what you can do about it.

Reason #1: You’ve exceeded your allowance for one or all of the items requested.

We work with many different types of insurance in Southern California: PPOs, government insurance, HMOs, medical groups and IPAs. While many of these payers base their coverage on Medicare standards, like their rates, there is a lot of variation between plans. For example, most PPO plans and Medicare will allow for one new mask every 90 days, while another plan only allows one new mask once per year! 

We recommend following the Medicare replacement schedule because routine replacement of supply components such as cushions, filters and tubing can have a profound effect on your comfort. If CPAP therapy is comfortable, you’re more likely to use your CPAP every night. That’s our goal.

Here’s the Medicare supply replacement schedule:

Even though your insurance may not cover the regular replacement of CPAP supplies outlined above, it is still extremely important that you replace the equipment anyway. Many of the components are not designed to last for more than a few weeks without replacement, such as mask cushions, and they may become uncomfortable and less effective when used for too long (read more aquí).
 

What to do if your insurance doesn’t allow more supplies:

• Call the member services department of your health insurance company. Tell them that you need to replace your CPAP supplies more often so that you can remain complaint. You can refer to the Medicare guidelines above or found online aquí. While your complaint may not change the outcome, a call to member services can sometimes get you a long way. At the very least, your making sure they hear that you take your therapy seriously and want them to follow Medicare guidelines.
• Talk to your equipment provider about paying cash for the minimum supplies that will get you through to your next full supply order through insurance. If your insurance only covers one mask per year, you should consider paying for a new mask every three months (that’s three masks per year that you buy out-of-pocket). You can use any HSA or FSA funds to pay for these supplies (read more about how these accounts work aquí). We’ve also compiled a list of organizations that provide free or low-cost CPAP supplies to those with financial need (see the link at the bottom of this post).
• Make sure that you are following the manufacturer’s guidelines for cleaning your mask assembly, tubing and filters. Daily cleaning can go a long way to making sure your equipment is in good shape for as long as possible (check out our recommended cleaning schedule aquí). This is especially important if you are trying to make your equipment last as long as possible.

Maximizing your health insurance benefits is essential. Make sure that you know as much as possible about what your health insurance coverage and work closely with your equipment provider and healthcare providers to take charge of your CPAP therapy.

We’ll cover the #2 reason why insurance companies won’t pay for replacement CPAP supplies in our next post. Stay tuned!

Fuentes:

• http://www.resmed.com/us/en/consumer/support/replacement/replacement-option.html
• https://oig.hhs.gov/oei/reports/oei-07-12-00250.pdf

Otros posts que pueden resultarle interesantes:

• ¿Con qué frecuencia debe sustituir los suministros de CPAP?
• ¿Debo pagar en efectivo mi máquina CPAP y los suministros?
• Cobertura de Medicare para CPAP y suministros
• Why is it Important to Choose an In-Network Provider? Learn the Facts.
• Help! I Can’t Afford CPAP. Where To Find Low-Cost or Free CPAP Machines and Supplies.