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Medicaid Advice?
#1
Medicaid Advice?
Hey, Apnea Board -

A few weeks ago I had a sleep study at a local hospital. It was only the preliminary test to determine whether I had sleep apnea, I was not hooked up to a CPAP machine at the time. I'm told that will come at a later date. A week after the study I requested my own medical record (because I'm impatient) and learned I have severe obstructive sleep apnea. I now have an appointment with a pulmonologist on Tuesday. My question is whether anyone else here has had experience getting their machine via Medicaid (Not Medicare). I have read the advice here on which machines to get, but I don't know what Medicaid will cover. Can I ask the doctor to prescribe an APAP machine such as the ResMed Airsense 10 AutoSet, etc., or since I'm on Medicaid will I be subject to whatever they say I can have? Any advice would be much appreciated!

Thanks
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#2
RE: Medicaid Advice?
Medicaid should cover the exact same things as Medicare, in most cases. 

Medicaid covers an auto-CPAP, since the billing codes are the exact same for a regular fixed-pressure CPAP and an auto-CPAP.  The DME (Durable Medical Equipment supplier) might not like dispensing an auto-CPAP, since they get the same money (around $1500) in reimbursement whether they dispense an Auto-CPAP or a regular CPAP, and their profit is lessened by giving you a more expensive auto-CPAP.

To get an Auto-CPAP, you'll first need to ask your doctor to give you and the DME a specific prescription for an Auto-CPAP (along with the range of pressures he suggests for it).

Do not let the DME bamboozle you into thinking you must pay extra for an auto-CPAP (called an "upcharge").  Nope, under both Medicaid and Medicare, you should not have to pay anything extra for an Auto-CPAP over a regular CPAP, as long as your doctor's prescription specifically states "Auto-CPAP".

But keep in mind, once you accept a machine, that's it. You can't go back later and say "Hey, my prescription is for an auto-CPAP and you gave me a regular CPAP!" -- nope... once you sign that you're accepting the machine, you're stuck with that machine for at least 5 years, unless you've got an extremely understanding and generous DME (not likely).

Coffee
SuperSleeper
Apnea Board Administrator
www.ApneaBoard.com


INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.


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#3
RE: Medicaid Advice?
You have to have the doc be very specific about the prescription. Do the research ahead of your appointment to decide which machine you want (sleepyhead compatible!!). Have him write prescription specifically for that, for heated hose and brand name filter if you want that. Patient choice on mask - you may be limited on masks, but not knowing what will work for you, you'll need some leeway on that.

My late brother was on Medicaid for some years and for some stuff, they give you the cheapest crap, whether it works for the patient or not. For other things, they were pretty good - but having the script rather specific helped 90% of the time.
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#4
RE: Medicaid Advice?
Thank you for the quick response, SuperSleeper! Are most doctors okay with prescribing APAP without having Central apnea, or will it require arm twisting on my part?

Thanks for the reply, Mosquitobait - as long as I can get the right machine, I'm willing to pony up for the right mask if I have to. But I definitely want as much control and data as possible - I'm determined to make this work!!
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#5
RE: Medicaid Advice?
APAP is not used to treat central apnea. And yes, many docs (especially younger ones) are more in favor of APAPs vs single pressure PAPs.

Medicaid varies from state to state but it should behave the same as Medicare, for the most part.
PaulaO

Take a deep breath and count to zen.




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#6
RE: Medicaid Advice?
I'm not suggesting I'm the Medicaid expert (I don't think that animal exists really), but I do have them as part of my insurance via the Commonwealth of PA welfare. I am certainly not sure of the gobbledygook insurance hierarchy I've got, but there's a United Healthcare Community and Medicaid combo I deal with as my providers.

That combo paid for my several sleep study and titration tests both for BPAP & ASV and the corresponding machines, masks, heated hoses, and all necessary supplies. Mine falls under a $0 deductible and $0 co-pay for all the above. Follow-up office visits are eventually billed to me as $1.00 co-pay. I'm quite certain they follow Medicare guidelines for replacement supplies, etc. and compliance.

The DME has not billed me NOR did I volunteer any credit card or other payment method other than an insurance plan info card. Friendly suggestion to follow same action; they don't need your credit or debit card info period.

YMMV depending upon your state of residence, but your likely experience should be similar.

Oh and you with your doc ought to discuss which specific xPap you desire and need; be very specific. ResMed, Respironics, etc. APAP, BPAP, ASV...whatever you decide is what I'm getting at. Decide about heated hose or not, mask probably should be listed as "patient choice". Make that script as specific as you can, and then get a paper copy of that script AND your PSG/Sleep studies/titration results. Best to ya! The "fun" is just getting started! Coffee
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#7
RE: Medicaid Advice?
I might suggest you go into the clinical menu and make sure to check machine hours so they don't try and show you the therapy hours. Medicare / Medicaid is paying for a new machine and that's what you should get since you won't get another for 5 years....Mike
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#8
RE: Medicaid Advice?
My FIL had AHI of 29, no centrals or anything special. He went to DME and walked out with an AirCurve 10 (BiLevel). He had not asked for anything and would never admit to any difficulty even if you hooked a vacuum cleaner up to his CPAP hose- he would insist that he was breathing just fine.
No idea if his doctor specified it or not.


Other than this example, I agree with everything said above. Welcome aboard
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#9
RE: Medicaid Advice?
Thanks for the advice, gang! We'll see how it goes tomorrow! I'm so thankful to find a helpful forum! We've got a very positive community here!

What do you recommend for filters? I've only considered machines and masks.
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#10
RE: Medicaid Advice?
(09-03-2018, 07:03 PM)Andyman Wrote: Thanks for the advice, gang! We'll see how it goes tomorrow! I'm so thankful to find a helpful forum! We've got a very positive community here!

What do you recommend for filters? I've only considered machines and masks.

I'll admit to not thinking about filters except when to change them or view if they happen to be dirty. I just get standard ResMed filters from DME. Simple is good... Coffee
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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