Getting CPAP on Missouri Medicaid insurance

I did some looking into if Missouri Medicaid (also known as MO HealthNet) will pay for CPAP and I found so interesting info here http://manuals.momed.com/collections/co ... /print.pdf (this might not be the same for all states so keep that in mind and is very possible it can change also make it easier on yourself and you find function of your browser for cpap this is a 450+ page document)
Here are the highlights
First of, yes they will cover it as long you had a sleep study done in a lab/ hospital (home sleep test results will not be taken) , diagnosed with apena (funnily enough nothing was mentioned about severity), if you get it pre authorized by your doctor, and the DME you go to takes Missouri Medicaid.

Your supply can't be automatically shipped to you, you must let your DME know you need them.

Missouri Medicaid will will rent the device for 12 months and after that you own it, they will still pay for supply and repairs as needed (as long you didn't intentionally break the device, if warranty would have covered it Missouri Medicaid should cover repairs for it)

For Missouri Medicaid to cover cpap more than the first 3 months you must meet with your DME provider or doctor no sooner than 61st day and basically give them your device's SD card so they can see if you are using it.

The part about spplies has be a bit confussed though 3.28.E SUPPLIES FOR RESPIRATORY ASSIST DEVICES (RADs) AND
CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) DEVICES
Supplies used with RAD and CPAP devices are covered when the coverage criteria for the
device is met. If the coverage criteria are not met, the supplies are not covered. Supplies,
repairs and maintenance are included in the first 12 months of rental reimbursement and are
not reimbursed separately. Providers must not dispense supplies simply because the quantity limitations allow. The participant must agree that replacement of supplies is desired and
necessary; no automatic shipping of supplies is allowed.
The supplies provided must be based on the type of delivery system the participant utilizes.
Supplies billed that are inconsistent with the delivery system utilized by the participant are
subject to denial or recoupment.
Procedure codes A7044 (oral interface used with positive airway pressure device, each) and
A7045 (exhalation port with or without swivel used with accessories for positive airway
devices, replacement only) are covered up to one every 180 days; however, these items are
rarely needed.
A non-heated (E0561) or heated humidifier (E0562) is covered separately when ordered by
the treating physician and pre-certified for use with a covered BIPAP device. A replacement
water chamber for a humidifier used with a positive airway pressure device (A7046) may
also be covered (a maximum of one per 180 days) when this replacement item is medically
necessary.
(If someone could help me make heads or tails of this that would be nice)

Also it looks like ( based on the chart near the end) that the max they will pay is $1024.32 (but that is also a bit confusing)

Ok that was long but I hope it helps someone else out and if I get a chance I will try and call the Missouri Medicaid office and get some of the fuzzy stuff cleared out

Which part about the replacement supplies is confusing to you?
Looks like they have adopted pretty much the typical Medicare replacement rules/allowances.

Verifying need can be done with a phone call, but YOU have to make it.
It is unusual for the supplier to demand physical proof for a filter or cushion,
but save the really icky ones for show and tell.

Pugsy wrote:Which part about the replacement supplies is confusing to you?
Looks like they have adopted pretty much the typical Medicare replacement rules/allowances.

(sorry I thought I put this in there after that but I must have forgot)
Dose it mean they will only pay for supplies for the first year I am on CPAP and then I have to pay after that. Also where it talks about on "oral interface used with positive airway pressure device" that I am guessing is the mask do I only get a new mask every 6 months and if something happens to my mask cushion would that be covered as matenice or would have to wait till the 6 month mark to get a new cushion or a new new mask. Also on the subject of masks, if I don't like the one I get with my CPAP am I stuck with it until I a) get to the 6 month mark b) buy a different one out of pocket and hope I like it better?

I didn't have time to go read the entire replacement schedule to see how it matches up with Medicare's replacement schedule.
Below is Medicare's replacement schedule and the corresponding HCPCS codes for each item and if you can find the HCPCS code for an item on the Medicaid schedule you will have an idea how the replacement process works.

Masks...general only 1 complete mask every 6 months. Now when first starting out therapy we don't always know which mask will work but insurance (medicare, medicaid or whatever) typically only will pay for the first mask. Each mask manufacturer allows 30 day return/trial per mask where a person can swap out masks and the DME supplier can fill out some paperwork and get credit for the unwanted mask. Often DMEs will make their own in house rules for mask swapping time because they don't want to do much paperwork. So they might tell you that your insurance doesn't allow anything but 1 per 6 months (which is true) and they don't tell you that the mask manufacturers have a program where the DME doesn't lose money. Or maybe they tell you that you have 30 days to swap masks to find one that suits you. When it comes to Medicaid patients it seems like they get treated like the ugly stepchild. It sucks but it happens. You have to clarify what the DME does in terms of mask swapping...they will make their own in house rules. My DME is fairly liberal with 60 days mask swapping and any number of masks during that 60 day period and it applies to me or to a brand new person. Only kink in it is that I have to return the unwanted mask to get a new one.

Replacement cushions usually are allowed at 1 per 30 days. The headgear and frame will usually last longer than 6 months with common sense care and depending on the cushion itself...the cushions can last months.

Generally replacement masks or cushions are covered after 1 year once it is proven that the person is still using the machine. I don't know what type of "proof" they will require. I haven't had to offer anything other than "I am doing great and I need so and so" for 6 years now (I am on Medicare) but some DMEs will require "proof" in the form of a quick download from the SD card that shows the machine is being used like it is supposed to be used.

There is always the private purchase route if you can afford it. Replacement parts don't require a RX so if by chance the cushion needs replacing there are sources that aren't too much of a hit on the wallet.
There's also the forum member source here... sometimes you can find what you need from a forum member who might have something you need or want and they don't want it for whatever reason.
I have a few masks that have been donated that I pass out to people if I happen to have what they need. These masks may have only been used to try on for fitting or maybe one night and the person just hated it and they couldn't return it for some reason.

It's always a good idea to have a spare of the basics laying around just in case something happens...like once my dog thought my nasal pillows that I had just washed (got knocked off the counter to the floor) was a new chew toy. Seems like if something bad is going to happen (mask gets torn or something breaks) it will happen on the weekend when DMEs are closed and getting a replacement is difficult when the office is closed even if the insurance will allow it.

Finding the right mask for first time cpap users is probably one of the most difficult issues that we have to sort through. Potentially made more difficult if the supplier wants to play hardball and not let the patient utilize the 30 day swapping thing that mask manufacturers have in place. Not many of us can afford to buy 3 or 4 masks out of our own pocket. I know that I couldn't. So find out exactly what your DME cpap supplier has in their mask swapping policy and make use of it if at all possible.

Pugsy wrote:I didn't have time to go read the entire replacement schedule to see how it matches up with Medicare's replacement schedule.
Below is Medicare's replacement schedule and the corresponding HCPCS codes for each item and if you can find the HCPCS code for an item on the Medicaid schedule you will have an idea how the replacement process works.

Masks...general only 1 complete mask every 6 months. Now when first starting out therapy we don't always know which mask will work but insurance (medicare, medicaid or whatever) typically only will pay for the first mask. Each mask manufacturer allows 30 day return/trial per mask where a person can swap out masks and the DME supplier can fill out some paperwork and get credit for the unwanted mask. Often DMEs will make their own in house rules for mask swapping time because they don't want to do much paperwork. So they might tell you that your insurance doesn't allow anything but 1 per 6 months (which is true) and they don't tell you that the mask manufacturers have a program where the DME doesn't lose money. Or maybe they tell you that you have 30 days to swap masks to find one that suits you. When it comes to Medicaid patients it seems like they get treated like the ugly stepchild. It sucks but it happens. You have to clarify what the DME does in terms of mask swapping...they will make their own in house rules. My DME is fairly liberal with 60 days mask swapping and any number of masks during that 60 day period and it applies to me or to a brand new person. Only kink in it is that I have to return the unwanted mask to get a new one.

Replacement cushions usually are allowed at 1 per 30 days. The headgear and frame will usually last longer than 6 months with common sense care and depending on the cushion itself...the cushions can last months.

Generally replacement masks or cushions are covered after 1 year once it is proven that the person is still using the machine. I don't know what type of "proof" they will require. I haven't had to offer anything other than "I am doing great and I need so and so" for 6 years now (I am on Medicare) but some DMEs will require "proof" in the form of a quick download from the SD card that shows the machine is being used like it is supposed to be used.

There is always the private purchase route if you can afford it. Replacement parts don't require a RX so if by chance the cushion needs replacing there are sources that aren't too much of a hit on the wallet.
There's also the forum member source here... sometimes you can find what you need from a forum member who might have something you need or want and they don't want it for whatever reason.
I have a few masks that have been donated that I pass out to people if I happen to have what they need. These masks may have only been used to try on for fitting or maybe one night and the person just hated it and they couldn't return it for some reason.

It's always a good idea to have a spare of the basics laying around just in case something happens...like once my dog thought my nasal pillows that I had just washed (got knocked off the counter to the floor) was a new chew toy. Seems like if something bad is going to happen (mask gets torn or something breaks) it will happen on the weekend when DMEs are closed and getting a replacement is difficult when the office is closed even if the insurance will allow it.

Finding the right mask for first time cpap users is probably one of the most difficult issues that we have to sort through. Potentially made more difficult if the supplier wants to play hardball and not let the patient utilize the 30 day swapping thing that mask manufacturers have in place. Not many of us can afford to buy 3 or 4 masks out of our own pocket. I know that I couldn't. So find out exactly what your DME cpap supplier has in their mask swapping policy and make use of it if at all possible.

Thank you. Do you know if CPAPs come with spear tubing or would I have to pick one up, my sister and I both have cats (mine is 6 years old and my sister's is 5 months old) and I am sure I don't need go anymore into that... extra tubeing might useful

Cpaps come with one hose with the unit, however you can order extra cats. Jim

Typically the cpap machine comes with humidifier (provided it is mentioned on the RX and it usually is) along with the long hose, a SD card for data collection and a travel case.
Unless the doc specifies "heated hose" on the RX they are usually supplied with the standard non heated hose.
The standard non heated hoses a generic and will fit all machines and are easy to find at various sources and are cheap. A lot cheaper than what DMEs will charge for them. Often if you shop smart you can pick up a couple for around $10 with free shipping. EBay is a good source for these types of items.
Heated hoses are more expensive but spares can also be found fairly easily.
I have cats. Funny thing is they have never once bothered any cpap hose I might have been using but they are hell on internet modems and cables (long story there). There are hose covers (called cozies) that can be used to protect the hose from furry claws and they also help with rain out prevention when a heated hose isn't used.

Fortunately hoses are probably one of the cheapest items we get with cpap therapy so it's pretty easy to have a couple of spares of at least the non heated standard hoses.

My cats just want to lay on the hose.

You can get a new cushion for your mask every month. If you damage your cushion before the new one comes, you'll have to pay out of pocket. Use an online supplier then. You will need a new prescription once a year for supplies (usually) through Medicaid. While the doc can write a supply prescription for 99 years, I don't think Medicaid will accept that (Medicare does more or less).

As to severity, I am guessing that again, they follow Medicare rules but leave it open ended because an appeal costs more than the machine and supplies.

SewTired wrote:My cats just want to lay on the hose.

You can get a new cushion for your mask every 3 months. If you damage your cushion before the new one comes, you'll have to pay out of pocket. Use an online supplier then. You will need a new prescription once a year for supplies (usually) through Medicaid. While the doc can write a supply prescription for 99 years, I don't think Medicaid will accept that (Medicare does more or less).

As to severity, I am guessing that again, they follow Medicare rules but leave it open ended because an appeal costs more than the machine and supplies.

For the new prescription is generally as simple as calling my doctor and they will send a new one to my DME, do I have to go just visit my doctor, or will have I need to have another sleep study to prove I still need it. Because I am 23 my doctor might just do it by a yearly basis for a while and see if it improves and if possible see about a multi year prescription if able.

pettyfan45 wrote:Because I am 23 my doctor might just do it by a yearly basis for a while and see if it improves and if possible see about a multi year prescription if able.

What improves? OSA is controlled by treatment using CPAP, but doesn't improve itself.

For the new prescription is generally as simple as calling my doctor and they will send a new one to my DME, do I have to go just visit my doctor, or will have I need to have another sleep study to prove I still need it. Because I am 23 my doctor might just do it by a yearly basis for a while and see if it improves and if possible see about a multi year prescription if able.

Unless you've had a big change (lost 50 pounds, have heart disease, etc), the doc isn't going to require you to have another sleep study (ok, famous last words, but there is no real reason to). Medicaid will not require another for your doc to renew the prescription.

SewTired wrote: . . .
You can get a new cushion for your mask every 3 months. . .

I was told that by my first DME, but my insurance (BCBSNE) had listed one per month.
Turns out, with the Mirage Quattro, they wanted to bill the cushion as the complete mask,
minus the headgear, but only giving me the CUSHION. Greedy, lying turkey basters!
I FIRED THEM.

chunkyfrog wrote:

SewTired wrote: . . .
You can get a new cushion for your mask every 3 months. . .

I was told that by my first DME, but my insurance (BCBSNE) had listed one per month.
Turns out, with the Mirage Quattro, they wanted to bill the cushion as the complete mask,
minus the headgear, but only giving me the CUSHION. Greedy, lying turkey basters!
I FIRED THEM.

My goof CF. It is every month (should be same as Medicare). I fixed it.

The whole system is so convoluted, it is sometimes impossible to get what you really deserve.
When I told the insurance company, they didn't even CARE.
So I fired their pet DME, and found another more willing to PLAY FAIR.