Seniors with Medicaid can feel confident that many types of medical supplies and equipment are available and covered under this program. One of the most common types of durable medical equipment is a continuous positive airway pressure (CPAP) machine. This article explains whether Medicaid covers CPAP machines, what you need to prove medical necessity, and whether living in a long-term care facility impacts your ability to get a CPAP machine.
As with many Medicaid services, scope, duration, limits, and other specific criteria can vary by state. The best way to confirm coverage is to speak with your health care provider or contact your state’s Medicaid program.
Why would I need a CPAP machine?
The quality and amount of sleep one gets can have a major impact on their health, but certain negative effects associated with bad sleep may affect the aging population even more. According to the Cleveland Clinic, poor sleep contributes to lack of energy, poor balance and coordination, mood changes, mental health issues, forgetfulness, and an increased risk of cardiovascular disease.
While there are many reasons for poor sleep quality, one common culprit is obstructive sleep apnea. This disorder causes the sleeper to repeatedly stop and start breathing when the throat muscles relax and block the airway, leading to subpar sleep quality. Individuals with sleep apnea may find relief with a CPAP machine, one of the most common treatments for obstructive sleep apnea.
CPAP machines are durable medical equipment
Durable medical equipment is a benefit category within Medicare and Medicaid. As long as the individual meets the requirements, people who need the types of items that fall into this category can receive help covering the costs involved with them.
According to the Centers for Medicare and Medicaid Services, an item is considered to be durable medical equipment if it:
- Can be used repeatedly.
- Has a main medical purpose.
- Isn’t useful to someone without an illness, injury, or medical condition that requires it.
- Can be used in the individual’s home.
CPAP machines are considered a type of durable medical equipment and are therefore eligible for coverage under Medicaid.
How do I get a CPAP covered by Medicaid?
A CPAP machine purchased outright can cost $1,000 or more, which may be too expensive for some. If you meet various eligibility requirements, Medicaid may help cover the cost.
Medicaid programs typically require a sleep study to further confirm your diagnosis and medical need. A sleep study measures brain activity, including how much time you spend in light and deep sleep, how much oxygen you are getting, how often you wake up, and other body movements. Medicaid will typically cover the cost of a medically necessary sleep study.
If, after consultation with your health care provider, it is determined that a CPAP machine is the best option to treat your condition, a written prescription will be the next step to obtaining your Medicaid-covered durable medical equipment.
Once completed, your provider may need to send all this information to your Medicaid program to get prior authorization or approval before you can receive your equipment. Once this process is completed, a sleep specialist or your health care provider will help you learn how to use the machine and ensure it is fitted properly.
States have different requirements for providing continued coverage of your CPAP machine. For example, in Florida, Medicaid requires a redetermination of medical necessity every 12 months by your health care provider, and in Michigan, Medicaid requires certain documentation beyond the initial four months of coverage to continue coverage of the machine. This is to confirm that the CPAP use continues to be effective and that you are compliant with the treatment.
Can I keep my CPAP machine?
Even though your equipment is considered a rental, it will typically become yours after you have rented it for a certain number of months, depending on your state’s Medicaid program. Medicaid will also cover any maintenance or repairs that your machine may need.
Can I still get this equipment if I live in a long-term facility?
Yes, the facility you live in will work with your health care providers to ensure you have all the equipment you need to treat your medical conditions, including CPAP machines. Some states may cover your equipment as part of the long-term care or nursing facility services, and some, like California, may cover it separately.
If you need to use a CPAP machine because you have sleep apnea but have limited financial resources, Medicaid may be able to cover the cost of the machine for you. If you’re not sure whether you have sleep apnea but are consistently tired despite sleeping for a typical amount of time, talk with your health care provider to learn if a CPAP machine could help your condition.
