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Medicare (US) and CPAPs - KSMatthew - 12-16-2023
I'm not quite to the Medicare age.
Currently on CPAP with self-pay. When I was on my employee plan I paid cash for a CPAP and did file an insurance claim with my employer-provided health insurance company so that I could apply it towards the deductible. Since my deductible was high enough, I basically paid out of pocket. Since then, I've retired, but I am on an ACA high deductible plan, so I still pay cash for everything CPAP related.
Pretty soon I'll be in the Medicare system. So, questions: Does Medicare require a recent sleep study before coverage? Does Medicare pay for a CPAP every x-months? And do you have to prove compliance? If I decide that Medicare isn't worth the trouble, does a "self pay" system still work out OK?
RE: Medicare (US) and CPAPs - Sleeprider - 12-16-2023
If at some point in your medical history you had a qualifying sleep test, a new test will not likely be required. The trick is to be sure you have the results from that test and a record of prescriptions since then. You should also start to establish a medical record with your treating physician of choice, so that your transition to Medicate is seamless. Medicate will continue to provide your supplies at 80% reimbursement from a participating provider, and if you have an advantage plan or other supplemental insurance, you could end up with full coverage. Your past insurance is irrelevant, but you need to get your records in order and work with a Medicare approved participating provider. A patient qualifies for CPAP after an in-person clinical evaluation and a positive sleep test using PSG or type II, III or IV home sleep test. While the criteria for a positive sleep test is defined as greater than or equal to 15 events per hour, or 5 or more events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke. The Medicare requirements can be found here https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=226
I summarized a lot of Medicare information in the Dealing with a DME wiki here https://www.apneaboard.com/wiki/index.php?title=Dealing_with_a_DME#DME_or_Sleep_Specialist_Says_I_Need_a_New_Sleep_Test
RE: Medicare (US) and CPAPs - srlevine1 - 12-16-2023
My DME (Apria at the time) handled the entire transition between employer-paid insurance and Medicare a few years after my retirement. I would suggest your first call be to the DME who provided the first machine to see if they are Medicare-qualified and will help you transition. It is in their best interests to capture ongoing business. They also may have a copy of your original sleep study, prescription, and some record of compliance.
Best -- steve
RE: Medicare (US) and CPAPs - KSMatthew - 12-16-2023
My first, and only, sleep study was >15 yrs ago. Apria was my first DME. Since then I’ve always paid out of pocket for all my CPAPs and supplies.
I do have annual compliance records.
RE: Medicare (US) and CPAPs - Sleeprider - 12-16-2023
Like you, my first and only sleep study was in 2008 and it was a 12 lead PSG clinical study. I retained a copy of the study summary and findings and keep a scanned version in my computer. That study has remained valid for supplies when I entered Medicare 8 years ago, and this past year when I received my first replacement under Medicare. There is no requirement that a new study be performed when you enter Medicare, only that the study that was done meets Medicare requirements (see post #2).