Does Medicaid Cover Sleep Apnea?
- 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.
Does Medicaid Cover Sleep Apnea?
Medicaid is run by state governments, and coverage can vary depending on your location. The Centers for Medicare & Medicaid Services support the use of different therapies such as CPAP for sleep apnea, and states generally follow this guidance. When seeking help for sleep apnea, you need to first get diagnosed, usually through a sleep study, and then treat the condition.
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 physician’s 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 Medicaid Cover CPAP Treatment?
The most effective treatment for sleep apnea is the use of a continuous positive airway pressure, or CPAP, machine. These machines deliver constant and steady air pressure to your airway as you sleep through a hose connected to a mask. In general, Medicaid does cover this sleep apnea treatment.
If you’re diagnosed with sleep apnea according to Medicaid’s criteria, the program will cover an initial 12-week period of CPAP treatment. Medicaid’s criteria determines how severe your sleep apnea is based on your apnea-hypopnea index (AHI). This index measures how often your breathing is interrupted each hour.
If your condition improves during the 12-week period and you’ve shown compliance with your usage of the CPAP machine, your treatment will continue to be covered in the future. The improvement of symptoms must be confirmed by your doctor or sleep specialist. The compliance requirement basically ensures that you’re using the machine enough to gain benefits. Currently, Medicaid requires that you use the machine for at least 4 hours a night, 70% of nights within the trial period.
Keep in mind that Medicaid’s benefits may not cover all costs, and you may need to pay for accessories such as filters and masks.
How Much Does a CPAP Machine Cost With Medicare?
Medicare’s coverage of sleep apnea generally follows Medicaid’s 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 you’ve met your deductible. Medicare covers 80% of the Medicare-approved rental cost of the machine and supplies such as filters and masks. You’re 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.
