A BiPAP/AVAP machine can cost anywhere from $950 to as much as $6,500 depending on the features it has.
They are covered by most
medical insurances. Although it is possible to purchase your own machine, the most common thing
is to rent one from a respiratory care company in such a way that you eventually own the
machine. I have found that renting a machine is well covered but sorting through the finances is
a headache. No one seems able to explain it fully. Therapists are seldom well versed in the
billing process and billing people only seem to know what your current statement shows. Anyway, the common way of
renting NIV machines is called Capped Rental.
Medicare and most private insurance companies do a capped rental on BiPAP/AVAP machines. As
with most durable medical equipment, they will pay 80 percent of the rental fee up for 13
months. Once they have paid that much in rental, the machine is considered paid for and is no
longer billed.
In the past, once the 13 months were up you were given the option of owning the machine but
not receiving any further visits, maintenance, or repairs from the supplier, OR agreeing
that the machine would continue to belong to the supplier and be returned to them if you no
longer needed it or changed supplier. With the second option, the supplier had a service contract
to provide visits by a Respiratory Therapist to check the machine or adjust the settings or help
you find the mask that works best for you. Maintenance, repairs, and replacement were the
responsibility of the supplier at no charge to you.
In 2006 Medicare dropped the second option by placing BiPAP/AVAP in the category of medical
equipment that does not need frequent or substantial servicing. Now, after 13 months the machine
belongs to you and the supplier has no service contract and provides no further services.
By 2016 machines such as the Trilogy, which can provide BiPAP/AVAP and, when needed, switch to
invasive ventilator settings were becoming common. These machines are considerably more expensive, so
Medicare changed their reimbursement to just two categories;
Respiratory support provided through a face mask or other non-invasive method.
Respiratory support provided invasively through a tracheostomy tube.
Rather than allowing the Trilogy to be filed as a BiPAP/AVAP machine, Medicare ruled that it must
be filed as a full, invasive vent regardless of how
it is used. The end result is that if you use a Trilogy as a BiPAP/AVAP, your co-pay may be considerably
higher than it would be for a NIV machine.
A BiPAP/AVAP machine is expected to last for at least 5 years and Medicare will pay for any needed
repairs for 13 months, but after that, the routine maintenance is up to you, as is dealing with mask problems and setting
changes. The loss of regular contact with a Respiratory Therapist who works closely with many
NIV users leaves users without a valuable resource.
Replacement of masks, tubing, etc. is 80% covered by Medicare on their time schedule: 90
days on masks, 2 pairs of nasal pillows and new tubing per month, 180 days on headgear.
There are no doubt variations from one insurance company to another, but it is likely that
insurers will follow Medicare's lead and end their service contracts with BiPAP/AVAP
suppliers.
