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Steven B. Ronsen updated their profile
Sep 15, 2018
Once again, I'm finding myself in a position of more confusion when I expected clarity.

I called my insurance HMO to ask what the replacement schedule was for masks, tubes, etc.

I was told that there's no schedule. Rather, if the cost is less than $350 all that I need is a prescription from my doctor, and if it's over $350 I need prior authorization.

My questions are:

1. What is the typical cost of replacement supplies? (The rep said she thought it was well above $350 but that sounds like a lot for a few pieces of plastic.)

2. How often should I be replacing these items?

Thank you!

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I recall seeing a schedule of what items are needed, and when they should be renewed. You might try a search on this site to find that page, but hopefully someone else remembers and will tell you (and me!).

You likely will find good information regarding the replacement schedule on your equipment manufacturer's website. If not, I'd just give them a call, and I'm sure they'll be able to give you specifics.

What brand/model equipment are you using?
most dme companies will fallow medicare guidelines, mask and hose =90 days headgear and water chamber = 180 days nasal pillows = 2 per 30 days disp. filter 2 = 30 days
Andy said:
I recall seeing a schedule of what items are needed, and when they should be renewed. You might try a search on this site to find that page, but hopefully someone else remembers and will tell you (and me!).

You likely will find good information regarding the replacement schedule on your equipment manufacturer's website. If not, I'd just give them a call, and I'm sure they'll be able to give you specifics.

What brand/model equipment are you using?

I'm using a Fisher and Paykel full face mask with a ResMed AutoSet II machine.
jeff duncan said:
most dme companies will fallow medicare guidelines, mask and hose =90 days headgear and water chamber = 180 days nasal pillows = 2 per 30 days disp. filter 2 = 30 days

Okay, so that's the Medicare recommendation? Thank you!
Do not replace a mask just for the sake of replacing it. Once you find a mask that you like keep it. You might want to get a back up. If you have a nasal get a full face mask just in case. Just replace the liners when needed. This might also earn you some favor with your insurance company. You never know when you are going to need it.
James,
Congratulations. Welcome to the world of medical liability costs.

Those "few pieces of plastic" carry with it the built in costs of liability to which the medical industry is susceptible to as a result of the unscrupulous legal community. These manufacturers have to "protect" themselves from the lawyers.

In so far as a replacement schedule, yes the majority of the insurance companies use the Medicare replacement schedule, but that is not written in stone. It is totally dependant upon your carrier and policy standards.

You need to contact your carrier and request, in writing, the standards of your policy. Make sure you get it in writing – CYA!

If the carrier refuses to provide you with their standards, contact the insurance commissioner for your state and they will assist you in getting it.

You may also want to get the "out of pocket" expense form from your insurance carrier also. They do have such a form and it must be provided to you upon request. If they refuse, the insurance commissioner's office will help you obtain it.

The DME has nothing to do with the time frame for replacements. All they care about is getting paid. Your pocket or the insurance company, someone will pay for it. Always remember, you are nothing more than $$$$$ when you walk into their business. No money source – no service.
Dan Lyon, does that "Out of Pocket Expense Form" also apply to Medicare??
Judy said:
Dan Lyon, does that "Out of Pocket Expense Form" also apply to Medicare??

Judy,
That would be a question I could not answer. Medicare, like the rest of the US government lives in it's own large, bottomless world. Is Medicare administered by the H&HS administration? If it is, I would call them and inquire. Most they can say is no.
Thanks, Dan Lyons. I needed a new nebulizer and I liked the one my family doctor had as it was smaller, quieter and faster than my 10 year old one that died so I asked him to write the script for that specific nebulizer. I had a local DME provider tell me that Medicare wouldn't pay for that particular nebulizer and another tell me that Medicare doesn't pay for nebulizers. So I bought the one I wanted out of pocket. But NOT before I discovered that the brand/model I wanted WAS eligible for Medicare reimbursement. The key was in finding a local DME provider who handled that particular brand. They just didn't want to special order that specific brand and model in for me.
Judy said:
Thanks, Dan Lyons. I needed a new nebulizer and I liked the one my family doctor had as it was smaller, quieter and faster than my 10 year old one that died so I asked him to write the script for that specific nebulizer. I had a local DME provider tell me that Medicare wouldn't pay for that particular nebulizer and another tell me that Medicare doesn't pay for nebulizers. So I bought the one I wanted out of pocket. But NOT before I discovered that the brand/model I wanted WAS eligible for Medicare reimbursement. The key was in finding a local DME provider who handled that particular brand. They just didn't want to special order that specific brand and model in for me.

Judy, so many people act like sheep and wander aimlessly down the path to which the "medical community" wants them to travel. They never question the answers to which these “professionals” provide.

Until these blind followers stand up, ask questions, and complain at the top of their voices about the lack of or laziness of a portion of the medical community, they are doomed to their own stupidity.

You want to change it, then you better be willing to use every tool that is at your disposal.

They sure don't mind using them to shut you, the patient, down.

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