Navigating Medicare and Medicaid
Understanding and interpreting the CMS (Centers for Medicaid & Medicare Services) guidelines when it comes to Sleep Testing and the payment of Treatment for Obstructive Sleep Apnea (OSA) can be challenging for anyone. We hope the information on this page will help clarify the entire process, from the initial doctor’s visit about suspected sleep issues, to receiving and maintaining the treatment.
We encourage you to become involved in this process. It is important to take each step in the order that CMS requires, or you may have to begin the process over again. We have created checklists that you can print at home and brought to your physician. If you are within five years of receiving Medicare benefits please use these checklists as they will provide a smooth transition to Medicare from your private insurance.
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- Face-to-Face Visit with your Provider or Sleep Specialist.
- This visit has to be Face-to-Face. It can not be done over the phone. The visit has to have everything listed in the CMS Checklist for Sleep Study Approval in the Provider’s report at the time of the visit. CMS will not accept addendums.
- Sleep Study within six months of the Face-to-Face visit.
- If you wait too long before scheduling the test (we generally have a two to three month wait for testing) you stand a chance to have to repeat the Face-to-Face visit.
- **If you are within 5 years of receiving Medicare benefits please advocate “to be scored by Medicare Standards”**
- Treatment Ordered within six months of the testing
- Face-to-Face Visit with your provider to download the machine and discuss the treatment within 31-90 days of receiving the machine (i.e. if you come in for this visit too early or too late CMS will not accept the information).
- The download of the machine must show compliance of use. CMS states that compliance is > 4 hours per night 70% of the time within a 30 day period.
- Should you not show compliance, the treatment device will be taken back by the Equipment Company and the entire process will have to be repeated.
- Your provider must have all the information listed in the CMS Checklist for Continuation of Supplies.
- Once again all the information on this checklist should be in the Provider’s report. An addendum or telephone conversation will not be permitted.
- Face-to-Face Visit with your Provider or Sleep Specialist.
- This visit has to be Face-to-Face. It cannot be done over the phone. The visit has to have everything listed in the CMS Checklist for Continuation of Supplies in the Provider’s report at the time of the visit. CMS will not accept addendums.
- Download must be completed from your current machine
- The download of the machine must show compliance of use. CMS states that compliance is > 4 hours per night 70% of the time within a current 30 day period.
- Should you not show compliance, you have to have another study and begin the process over again. See Initial Start to Investigate a Sleep Disorder above.
*People who require oxygen during the day do not fall under these rules*
- If the patient has, or is suspected to have sleep apnea, patient must be tested in a facility setting to prove PAP (Positive Airway Therapy) therapy does not work on it’s own and oxygen is needed to supplement the treatment.
- No home testing is allowed currently.
- CMS will no longer pay solely for Nocturnal Supplemental Oxygen should patient have the diagnosis of Sleep Apnea. The Sleep Apnea patient must be using PAP therapy in order to be in consideration for oxygen.
- The patient must maintain PAP compliance (using the machine > 4 hours a day 70% of a current 30 day window).
- Should a person show non-compliance:
- They will not have oxygen approved by CMS
- They will not get PAP supplies approved by CMS
- If the PAP machine is a newly purchased, this too will be not approved by CMS and they will have the DME pick up the machine from your house.
- The entire process will have to be started over per CMS guidelines