Medicaid CPAP Insurance Policies / Requirements
Do you already have Medicaid? Are you interested in enrolling in Medicaid in the future? In order to get reimbursed for insurance-eligible CPAP products, you must follow a few guidelines that may not be so intuitive.
Similarly, if you have already been using CPAP therapy under a different insurance plan, but are looking to switch to Medicaid, you must follow all of their policy guidelines. This means that the initial doctor’s visit is required to have your CPAP covered by Medicaid, even if you have be a CPAP user in the past.
Medicaid Policies for CPAP Reimbursement
- Face to Face Evaluation with a Physician
- CPAP Compliance
Face-to-Face Meeting with a Physician
In order to comply with Medicaid’s standards, it is necessary that any patient that intends to have their CPAP therapy covered attends a medical evaluation with a physician of their choice. During this appointment, you must receive documentation of symptoms of Obstructive Sleep Apnea (OSA), a complete Epworth Sleepness Scale, Body Mass Index (BMI), neck circumference, and a focused cardiopulmonary and upper airway system evaluation.
The doctor’s appointment must come after a baseline sleep study has been conducted.
Many insurance companies require that “compliance” while using CPAP Therapy is maintained to a certain extent. Many companies follow the Medicaid Compliance requirements. Simply put, compliance is defined as us of PAP devices for 4 or more hours per night on 70% of nights (21 out of 30 nights) during a consecutive 30 day period. If you would like to learn more in-depth about compliance, visit Health Sqyre’s How to be Compliant Help Page!