Does Medicaid Cover Home Sleep Studies

Date:

Cms Requirements For Nocturnal Supplemental Oxygen

Home Sleep Study

*People who require oxygen during the day do not fall under these rules*

  • If the patient has, or is suspected to have sleep apnea, patient must be tested in a facility setting to prove PAP therapy does not work on its own and oxygen is needed to supplement the treatment.
    • No home testing is allowed currently.
    • CMS will no longer pay solely for Nocturnal Supplemental Oxygen should patient have the diagnosis of Sleep Apnea. The Sleep Apnea patient must be using PAP therapy in order to be in consideration for oxygen.
  • The patient must maintain PAP compliance .
    • Should a person show non-compliance:
      • They will not have oxygen approved by CMS
      • They will not get PAP supplies approved by CMS
      • If the PAP machine is a newly purchased, this too will be not approved by CMS and they will have the DME pick up the machine from your house.
      • The entire process will have to be started over per CMS guidelines

    Oklahoma Health Care Authority Eliminates Sleep Testing And Pap Coverage For Medicaid Adults

    During the March 24 meeting of the Oklahoma Health Care Authority , its Board decided to eliminate coverage of sleep studies and positive airway pressure treatment for adults 21 and older who are insured by Medicaid. For months the AASM had engaged members in Oklahoma on this issue, and the AASM also opposing the proposals, warning that their implementation could lead to devastating health complications for Medicaid beneficiaries who suffer from untreated obstructive sleep apnea.

    The Board communicated that it recognizes the potential medical benefits of sleep studies and PAP therapy. However, the OHCA considered these services to be optional, and the difficult decision to eliminate coverage for them was made at a time when the OHCA faced a severe budget shortfall.

    The AASM will continue to advocate to reinstate coverage for these two important services for the 782,000 Oklahomans who are enrolled in the Medicaid or CHIP program. Without coverage for sleep studies and PAP therapy, a significant portion of the states population will experience a burden in accessing necessary medical care for their chronic sleep disease.

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    Medicare Approves Coverage For Home Sleep Studies

    • News
    • Medicare Approves Coverage for Home Sleep Studies

    Countless snorers have no doubt thought, as they packed up their jammies and headed to the sleep lab for an overnight study, Boy, it sure would be nice if I could do this at home in my own bed. In fact, home studiesalso known as portable monitoringhave been around as long as CPAP. But persistent questions about their reliability, and the consequent refusal of most insurers to pay for them, have kept them out of the mainstream of practice.

    Thats all changing. In March, the Centers for Medicare and Medicaid Services, whose reimbursement rules are generally adopted by private insurers, dropped its long-standing opposition to home studies. According to the National Coverage Determination that was released that month, a diagnosis of obstructive sleep apnea can be madeand CPAP therapy coveredon the basis of a clinical evaluation coupled with a home study using a device that measures, at a minimum, airflow, heart rate, and oxygen saturation.

    A positive diagnosis is established if: The apnea-hypopnea index as measured by the portable device is 15 or more or the AHI is between 5 and 14 and the patient has documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders, hypertension, ischemic heart disease, or history of stroke.

    The NCD specifies that the home study must be ordered and supervised by the treating physician. It also limits the initial coverage of CPAP to a 12-week trial period.

    Medicare Coveragae For Cpap Machines

    Home sleep testing  safe and effective

    The most common type of sleep apnea is obstructive sleep apnea. This is when the soft tissue at the back of the throat collapses during sleep.

    Smoking cessation and other lifestyle changes can sometimes keep sleep apnea at bay. However, if your condition is moderate to severe, it may require further treatment.

    Most often, sleep apnea is treated with the use of continuous positive airway pressure, or CPAP, machines. Patients use these machines with breathing masks during sleep.

    Medicare partially covers the cost of a CPAP machine as durable medical equipment.

    To avoid additional costs, be sure your equipment comes from a supplier accepting Medicare assignment.

    Additionally, required supplies for a PAP machine receive coverage through Medicare. The Part B deductible applies to all equipment.

    If you have a Medigap plan, it will pick up the remainder of the cost. For those with Medicare Advantage, copays, network restrictions, and deductibles could apply.

    Check with your provider before scheduling a sleep study or getting sleep apnea treatment equipment.

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    Sleep Studies For Diagnosing Obstructive Sleep Apnea

    Sleep studies are often required to formally diagnose patients with sleep apnea.

    You must undergo a face-to-face evaluation with your doctor prior to your sleep study. Your obstructive sleep apnea symptoms must be documented in your medical record before your doctor writes an order or referral for a sleep study.

    Four Types of Sleep Studies Covered by Medicare

    Type I
    This type of attended sleep study is covered by Medicare when it is performed at a facility with the oversight of a sleep technologist to aid the diagnosis of obstructive sleep apnea. Type I, which is typically performed in a facility, is considered the reference standard for diagnosing obstructive sleep apnea.
    Type II
    Type II is a home sleep test performed using a portable monitor with a minimum of seven channels. Medicare covers Type II testing to diagnose obstructive sleep apnea whether it is performed attended or unattended by a sleep technologist.
    Type III
    Type III is a home sleep test performed using a portable monitor with a minimum of four channels. Medicare covers Type III testing to diagnose obstructive sleep apnea whether it is performed attended or unattended by a sleep technologist.
    Type IV
    Type IV uses at-home sleep study devices that measure, at a minimum, three channels: airflow, heart rate and oxygen saturation. Medicare covers Type IV testing to diagnose obstructive sleep apnea whether it is performed attended or unattended by a sleep technologist.

    Supplemental Medicare Coverage For Sleeping Problems

    Although Original Medicare helps cover seniors with certain sleeping disorders, it does not cover everything. If you have been diagnosed with sleep apnea and need additional coverage, you may want to consider a Medicare Supplement Plan .

    Get a quote from Medicare.org. We offer free comparisons for Medicare Advantage Plans , Medicare Supplement , and Medicare Prescription Drug Plans. Contact a licensed sales agent at TTY 711 to help you find the right Medicare coverage for your needs.

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    A Medigap Plan Can Help Pay For Sleep Apnea Medicare Costs

    The cost of sleep apnea testing and treatment can be lowered even more with the help of a Medicare Supplement Insurance plan.

    There are eight standardized Medigap plans that fully cover the cost of the 20% Part B coinsurance payment required for covered sleep apnea testing and CPAP machine treatment.

    A licensed agent can help you decide on a Medicare option that works for you. Call today to speak with a licensed agent and compare the Medigap plans that are available where you live.

    Is There A Downside To Home Sleep Testing

    Home sleep study, what’s it like??

    For most people, the biggest risk of a home sleep apnea test is the potential for being misdiagnosed as not having obstructive sleep apnea when they actually have it, or as having a milder version than they actually do. For this reason, doctors often order an in-lab sleep study when a home sleep study comes back negative.

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    Repeat Sleep Study Indications

    It may be necessary to perform repeat sleep studies up to twice a year for any of the following indications. performed in a healthcare facility is considered medically necessary for persons who meet criteria for attended NPSG in section I above in all other cases, unattended sleep studies are considered medically necessary):

  • To determine whether positive airway pressure treatment , demand positive airway pressure , variable positive airway pressure , or auto-titrating positive airway pressure ) continues to be effective in persons with new or persistent symptoms, after interrogation of current positive airway pressure device or
  • To determine whether positive airway pressure treatment settings need to be changed in persons with new or persistent symptoms, after interrogation of current positive airway pressure device. or
  • For persons with substantial weight loss or some other change in their medical condition that would affect the need for continued positive airway pressure treatment , to determine whether continued treatment with positive airway pressure treatment is necessary or
  • To assess treatment response after upper airway surgical procedures and after initial treatment with oral appliances.
  • Note: A home sleep study is performed over multiple nights with a single interpretation is considered a single sleep study for purposes of reimbursement.

    Does Medicare Cover Cpap

    Medicare considers CPAP devices to be durable medical equipment and provides 80% coverage under Part B as long as you meet certain conditions. First, your doctor must diagnose you with obstructive sleep apnea following an approved laboratory sleep study or an at-home sleep study, and give you a prescription for a CPAP machine.

    Then, Medicare covers a 12-week initial period of CPAP therapy for obstructive sleep apnea, as long as you meet the following requirements:

    • You have an hourly AHI between 5 and 14 and a comorbid condition related to obstructive sleep apnea, including hypertension, history of stroke, heart disease, excessive daytime sleepiness, insomnia, mood disorders, and impaired cognition or
    • You have an hourly AHI of 15 or higher.

    You must also meet Medicares compliance requirements, which state that you must use the machine at least 4 hours per night, 70% of the time or more, during the first 3 months. If you fail to meet these requirements, you have to begin the process again. This involves completing another sleep study, either in a lab or at home, and obtaining another prescription from your doctor.

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    Compliance Monitor For Oral Appliances

    The American Academy of Sleep Medicine and the AADSMs clinical practice guideline on The treatment of obstructive sleep apnea and snoring with oral appliance therapy stated that There are several recent non-RCTs published that report on the use of objective adherence monitors in OAs. Further RCTs are needed to evaluate the efficacy of these monitors and also to compare it with the CPAP objective adherence rate.

    Furthermore,, an UpToDate reviews on Oral appliances in the treatment of obstructive sleep apnea in adults does not mention the use of compliance monitors.

    What If I Dont Want To Pay With Insurance

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    Sometimes patients review their coverages, then look at their cash pay options, and decide to skip insurance coverage because its less expensive to pay cash. We offer a cash pay rate thats discounted for this reason. People without insurance can also enjoy the cash-pay discount for services we provide.

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    How Much Do Sleep Studies Cost With Medicare

    If you show symptoms of sleep apnea and your doctor orders testing, Medicare will help pay for Type I, II, III and IV sleep studies.

    • Even if your sleep study is covered by Medicare, Medicare requires that you pay 20 percent of the Medicare-approved costs of the study.

    • Additionally, youll have to pay any part of your Part B deductible that you havent yet met. In 2019, the Part B deductible is $185 per year.

    A Medicare Supplement Insurance plan can help pay for your sleep study Medicare out-of-pocket costs.

    In most states, there are up to 10 standardized Medigap plans to choose from.

    What Is An At

    A home sleep apnea test is an overnight test conducted outside of a hospital or sleep lab. HSAT can also be referred to as a home sleep test , an out-of-center sleep test , out-of-center recording, or polygraph . This type of testing can accurately diagnose obstructive sleep apnea in some, but not all, people. Often, home sleep apnea testing costs less and is viewed as more convenient than an in-lab sleep study, because it takes place in the comfort of a persons home.

    When undergoing a home sleep apnea test, you generally have to pick up special equipment from your doctors office or a sleep clinic. Then, you carefully follow the instructions provided regarding how to use the various test devices given to you. You sleep as you usually would, except with specific devices connected to your body to collect data, for at least one night.

    After the test is completed, the equipment must usually be returned, although some newer tests are disposable. A sleep specialist will analyze the data to see if you meet the criteria for obstructive sleep apnea.

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    Does Medicaid Cover Sleep Studies

    Yes, sleep studies are covered by Medicaid in most states. The study must be recommended by a health care provider or sleep specialist after a face-to-face visit and must be conducted within 6 months of this initial appointment.

    To be covered, your sleep study must be supervised by:

    • A hospital-based sleep lab
    • A sleep clinic that is a direct extension of a physicians office
    • An independent diagnostic testing facility
    • An out of center sleep testing entity accredited by the American Academy of Sleep Medicine

    At-home testing is only covered under special circumstances.

    Does Health Insurance Cover Sleep Studies

    Obstructive Sleep Apnea Part 3: Sleep Studies

    Yes, usually.The less-than-satisfactory answer is, It depends. But by and large, all insurance payers offer some sort of reimbursement for sleep studies of all kinds.

    This is one of the biggest questions we field from patients at the sleep center. They are reasonable to ask whether they have adequate coverage for an upcoming sleep test, which they understand can be more expensive than many other kinds of medical tests.

    Last week we posted an article giving our particular rates for various kinds of sleep tests. These rates define the price for services we charge before insurance reimburses you for them. Theyre frequently much higher than what patients actually pay .

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    Does Medicaid Cover Cpap

    Many sleep study diagnoses are treated using therapies such as CPAP, particularly for beneficiaries experiencing severe and unambiguous obstructive sleep apnea. The use of CPAP is covered under Medicaid when prescribed by the attending licensed technician.

    However, if the beneficiary has been utilizing CPAP therapy under a different insurance plan and is looking to switch to Medicaid, the issue requiring CPAP may be considered a preexisting condition. In this case, the beneficiary must first be found in accordance with all applicable policy guidelines. This typically includes an initial doctors visit, even in the event that you are currently using CPAP therapy or have in the past.

    To find out more about how much your sleep study may cost you, talk to your doctor or health care provider.

    What Is The Cost Of A Sleep Study With Insurance

    Its nearly impossible to capture all of the variations in reimbursement schedules from one insurance payer to the next, especially with so many different avenues for applying insurance benefits .

    However, here are some highlights and generalized guidelines for determining if, how, and when your insurer will cover your sleep study.For the purposes of this post, the discussion centers only on private insurance carriers and not CMS/Medicare/Medicaid.

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    How Much Does A Cpap Machine Cost With Medicare

    Medicares coverage of sleep apnea generally follows Medicaids guidelines. To be covered, you must get a positive diagnosis of sleep apnea by completing a sleep study, and you also get a CPAP machine for an initial 12-week test period. If the machine helps, Medicare will continue to pay a share of the machine rental for 13 months, as long as you use it continuously, and after 13 months you own the machine.

    This coverage follows general Medicare Part B rules. This means that the deductible does apply, and benefits only start after youve met your deductible. Medicare covers 80% of the Medicare-approved rental cost of the machine and supplies such as filters and masks. Youre responsible for the other 20%, plus any difference between what the supplier charges and the Medicare-approved amount. You must also source the machine through a Medicare-approved supplier. As costs for CPAP machines can range from $250 to upwards of $1000, this Medicare coverage can help make healthy sleep affordable for many people.

    Does Medicaid Cover Sleep Apnea

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    • Does Medicaid cover sleep apnea? Discover more about sleep apnea, how diagnosis and treatment is covered by Medicaid and CPAP machine costs with Medicare.

    Sleep apnea can be a very serious condition, causing the upper airway to partially or completely close during sleep. An estimated 22 million Americans with sleep apnea experience poor sleep interrupted by snoring, gasping or choking. Proper treatment can help improve sleep and prevent other health problems including daytime tiredness, cardiovascular issues and liver disease, and knowing whether Medicaid covers sleep apnea can help you plan your treatment.

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