How It Works

We are a Medicare Authorized CPAP Provider and accept Medicare assignment. This means we submit a claim to Medicare and are paid based on their standard allowable rate for CPAP equipment.

If you are a Medicare beneficiary with diagnosed Sleep Apnea and have not received supplies in the last 180 days, then you can choose from a wide selection of CPAP Supplies including CPAP Masks, Humidifiers, Filters and Tubing that will be delivered to your door!

Our company has been processing Medicare claims for 17 years and we can work with you to make the process easy. We file your claims to Medicare and to your Secondary Insurance. You can fill out our web based form to check your coverage or call us toll free. You are under no obligation to enroll with us and there is no time limit on your call; you are free to spend as much time learning about the process and asking questions as you need.

You may receive these benefits without any changes to your existing Medicare benefits.

In order to bill Medicare on your behalf, we do need some information from you. Once we collect all your information and verify your coverage, we can send out your equipment.

Also, if you choose to receive reminders, we can send you new equipment on Medicare's allowed schedule with your consent.

Overview

Medicare pays 80% of CPAP/BiPAP equipment rental as well as covered supplies for all eligible Medicare beneficiaries. Payment of the remaining 20% (referred to as a copay) is the responsibility of the patient or their secondary insurance carrier. The 20% copayment and unmet deductible may be collected at the time of shipping.

Supplies

Medicare covers 80% of the cost of most CPAP/APAP/BiPAP supplies (Masks, Headgear, Filters, etc).

Machines

Medicare will typically cover 80% of the cost of CPAP/APAP/BiPAP Machines. Machines are purchased via a 13 month rental process. Medicare guidelines do not allow for the direct purchase of CPAP/APAP/BiPAP Machines.

CPAP/APAP/BiPAP Machines are purchased via a capped rental process during which Medicare is billed at a monthly rental rate that will be converted to purchase after 13 months of rental. You own the equipment after the 13th rental month.

Deductible

All Medicare beneficiaries have a $131.00 deductible per year. The Medicare deductible for 2008 will be $135.00. Payment of the $131.00 deductible amount is the responsibility of the patient or their secondary insurance carrier. By Medicare guidelines, the deductible can not be waived, nor negotiated.

Medicare provides guidelines for beneficiary receipt of CPAP and Sleep Apnea related equipment. This means that you can be regularly provided you with brand new CPAP equipment through our services. Here is a quick reference chart of supplies and their allowed rates of re-order:

With your permission, we will keep your information on file so that when it's time for new supplies, you won't have to give us more paperwork; just indicate your preferences when we remind you, let us know what you need and your equipment will be shipped to your doorstep!

After your first order with us, you'll be eligible for new products periodically. You can choose how you would like to be reminded:

• Follow Up With Me By Phone.
  • We will follow up with our patients regularly via phone to check on their treatment status.
• Follow Up With Me By Email.
  • We will follow up with our patients regularly via email to check on their treatment status.
• Do NOT Monitor My Status.
  • For patients who are making one-time transactions.
  • We will not follow up with these patients to track their treatment status.*

• Are you (the Medicare beneficiary) now using a machine that helps you take your breaths while you are asleep (separate from a machine that may be giving you oxygen or medicine)?
• How many hours per day do you usually use this machine?
• How many months have you been using this machine?
• Will you keep using this treatment in the future?

• Secondary Insurance
• Letter of Medical Necessity (LMN)
  • Only if the LMN you submitted to us during your first order did not have a lifetime duration stated.

We need the following information to process your first order:

Patient Information

• Full Name
• Phone Number
• Social Security Number
• Date of Birth
• Mailing Address Medicare Has On File

Medicare Information

• Do you currently own CPAP equipment?
• Do you currently have CPAP equipment on rental/maintenance with another provider? If so, which provider?
• Have you received CPAP equipment or supplies in the last 180 days?
• Medicare Number
• Social Security Number
• Physician Information
  • Name
  • Phone
  • Fax
  • Address
  • UPIN

Payment Information

• Secondary Insurance (If Applicable)
  • Name
  • Insurance ID
  • Insurance Group Number
  • Insurance Address
  • Policy Holder Name

We are able to quickly review and evaluate your documents. We will send you an easy to read report outlining whether or not your documents qualify you as a CPAP Medicare beneficiary. Our reports will break down each requirement and explain how you can work with your doctor to gather all needed information.

Sleep Study (Attended Polysomnogram)

What is this?

When a doctor diagnoses a patient with OSA (Obstructive Sleep Apnea) the next step is to confirm the diagnosis and learn how severe a patient's OSA is. The process usually involves an overnight visit to a Sleep Clinic or Sleep Center where the patient is monitored and recorded.

An Attended Polysomnogram Study reports the findings of a Sleep Center. It rates the severity of a patients OSA. It is used by Medicare to determine if a patient has severe enough OSA to qualify for coverage.

How Recent Must It Be?

Sleep studies do not expire. As long as your study meets the requirements discussed below and a copy can be obtained it is valid.

Components

Before we can dispense equipment our patient must have visited an attended sleep lab facility and been diagnosed with Obstructive Sleep Apnea (OSA).

To receive equipment under Medicare, a patient's Sleep Study results must meet one of the following sets of requirements:

• The apnea hypopnea index (AHI) must be greater than or equal to 15 events per hour
  • Data must be explicitly stated, not extrapolated.
• The diagnostic portion of the sleep study must reflect 2 hours or longer of diagnostic sleep time.
• The diagnostic portion of the sleep study must be performed in an attended sleep lab facility.

• The AHI must be from 5 to 14 events per hour with documented symptoms of:
  • Hypertension, history of stroke or ischemia heart disease.
  • Excessive daytime sleepiness, impaired cognition, mood disorders or insomnia.
• The diagnostic portion of the sleep study must reflect 2 hours or longer of diagnostic sleep time.
• The diagnostic portion of the sleep study must be performed in an attended sleep lab facility.

Medicare is not flexible with these requirements and by law we may not vend equipment to Medicare patients who do not meet these guidelines.

Letter of Medical Necessity (LMN) or Prescription (Doctors Written Order)

What is this?

A prescription is an order written by a doctor stating that a patient is in need of equipment.

A Letter of Medical Necessity or LMN is a prescription, order or letter that states "lifetime duration" or "lifetime need". Typically, an LMN provides greater detail about the need for equipment and additional dispensable supplies. This is our preferred document since it means you will have to submit less documentation in the future.

Components

We must have an order from the doctor before dispensing equipment to our patient. The dispensing order must include:

• Description of the item(s) prescribed
• Duration of each item
  • Lifetime duration is ideal, but not required
• Beneficiary's name
• Name, UPIN and License Number of the Physician
• Date of the order
• Diagnosis Code

Medicare Websites

Palmetto GBA
Centers for Medicare and Medicaid Services
US Government Medicare Website