Your Guide to Getting New PAP Supplies
You depend on your PAP equipment to help you sleep each night and treat the symptoms of sleep apnea. But in order for your treatment to be effective, you need to make sure your PAP equipment and supplies are in good working order. This means knowing when it's time to replace certain supplies and components associated with your therapy to ensure you're getting the best possible results. With this PAP Supply Replenishment Guide from Performance Home Medical, our goal is to help you learn more about when you can get new PAP supplies through Medicare and Medicaid programs. For a better understanding of how the guidelines apply to the state you live in within our service area, click the links below.
PAP Compliance Guidelines - First 90 Days
Medicare and Medicaid, as well as most private insurance plans, have adopted the following PAP compliance guidelines, which must be met during the initial 90-day “trial” period to qualify for continued use or purchase after the first 3 months of use.
In the first 90 days, you must have at least one (1) documented* consecutive 30-day period where you:
- Used the PAP device for at least 4 hours per night for 21 of those 30 nights.
PLUS
You must have a face-to-face clinical re-evaluation by your doctor between the 31st and 91st day. Your doctor must document the following in chart notes:
- That your symptoms of sleep apnea have improved. AND
- That the objective evidence* of PAP “compliance” has been reviewed and placed in your medical record.
* Actual use data from your equipment
Once you have met all these requirements, insurance will resume payment for the rental and/or purchase of the PAP equipment, and future replacement supplies when needed, as long as you continue to be benefit-eligible.
PAP Compliance Guidelines - Medicare
Unfortunately, if you do not meet these requirements exactly, Medicare compliance requires that you either return the equipment to the supplier or pay for the equipment and future replacement supplies privately. To try PAP therapy again, your physician will need to prescribe another sleep study (at a facility-based lab) and you will be required to begin another PAP compliance trial period.
PAP Compliance Guidelines - Medicaid
Unfortunately, if you do not meet these requirements exactly, Medicaid requires that you return the equipment to the supplier immediately. To try PAP therapy again, your physician & Medicaid will need to determine if a new sleep study is appropriate by understanding your compliance issues. If appropriate, your physician will determine the next steps and work with your supplier to assist you.
Can My Supplier Lend a Hand?
YES, your supplier should be on your team! They should:
- Follow up with you to see how you are doing and answer your questions.
- Arrange for a “mask refit” if you are having difficulty with your interface, mask, or equipment.
- Coach you with feedback to know if you are “compliant,” or what you need to work on.
- Be available to answer your questions, make suggestions, or recommendations.
- Support and encourage you!
Is There a Secret to Compliance?
Make a commitment to improve your life by taking ownership of your health. Ask your family for support, not jokes.
- Practice using your mask during the day and/or before you go to bed.
- Use the “ramp” feature to gradually increase the pressure as you fall asleep.
- Learn to adjust your mask & headgear, not just tighten it.
- Keep your interface clean to minimize leaks and maintain a therapeutic fit.
- Replace your supplies regularly; they deteriorate gradually and can minimize your treatment.
- Talk to your equipment supplier about issues sooner rather than later.
- Talk to your doctor.
- Be consistent, patient, and don’t give up!
Need to reach us?
Office hours: Monday through Friday,
8:30 AM – 5 PM
Phone: 1.866.687.4463
Email: [email protected]
You can also contact us online by completing our online form.
Medicare & Medicaid Washington State PAP Coverage Requirements
Regular replacement of PAP supplies is covered by Medicare, Medicaid, and private insurance plans, and is essential for ongoing comfort, compliance, and cleanliness. With regular use, these items deteriorate over time, which is usually not noticeable until they have been replaced. Medicare and Medicaid maximum replacement frequency is:
Nasal mask:
- Medicare: 1 per 3 months
- Medicaid: 1 per 6 months
Replacement nasal cushion/pillow:
- Medicare: 2 per 1 month
- Medicaid: 1 per 3 months
Full face mask:
- Medicare: 1 per 3 months
- Medicaid: 1 per 6 months
Replacement full face cushion:
- Medicare: 1 per 1 month
- Medicaid: 1 per 3 months
Tubing:
- Medicare: 1 per 3 months
- Medicaid: 1 per 6 months
Both plans:
Headgear: 1 per 6 months
Chinstrap: 1 per 6 months
Disposable filter: 2 per 1 month
Washable filter: 1 per 6 months
Water chamber: 1 per 6 months
NOTICE TO PHM PATIENTS:
If you wish to purchase additional supplies more frequently than your insurance allows, we suggest that you check competitive pricing on the internet. Suppliers with a Medicare/Medicaid supplier contract have variable requirements by plan that may limit our ability to provide additional items directly to patients. Internet suppliers are not restricted by these requirements.
Medicare & Medicaid Idaho State PAP Coverage Requirements
Regular replacement of PAP supplies is covered by Medicare, Medicaid, and private insurance plans, and is essential for ongoing comfort, compliance, and cleanliness. With regular use, these items deteriorate over time, which is usually not noticeable until they have been replaced. Medicare and Medicaid maximum replacement frequency is:
The below is for both Medicare & Medicaid.
Nasal mask: 1 per 3 months
Replacement nasal cushion/pillow: 2 per 1 month
Full face mask: 1 per 3 months
Replacement full face cushion: 1 per 1 month
Tubing: 1 per 3 months
Headgear: 1 per 6 months
Chinstrap: 1 per 6 months
Disposable filter: 2 per 1 month
Washable filter: 1 per 6 months
Water chamber: 1 per 6 months
Note: Medicaid does not provide 90-day refills. Supplies will follow the above refill schedule.
NOTICE TO PHM PATIENTS:
If you wish to purchase additional supplies more frequently than your insurance allows, we suggest that you check competitive pricing on the internet. Suppliers with a Medicare/Medicaid supplier contract have variable requirements by plan that may limit our ability to provide additional items directly to patients. Internet suppliers are not restricted by these requirements.
Medicare & Medicaid Oregon State PAP Coverage Requirements
Regular replacement of PAP supplies is covered by Medicare, Medicaid, and private insurance plans, and is essential for ongoing comfort, compliance, and cleanliness. With regular use, these items deteriorate over time, which is usually not noticeable until they have been replaced. Medicare and Medicaid maximum replacement frequency is:
The below is for both Medicare & Medicaid.
Nasal mask: 1 per 3 months
Replacement nasal cushion/pillow: 2 per 1 month
Full face mask: 1 per 3 months
Replacement full face cushion: 1 per 1 month
Tubing: 1 per 3 months
Headgear: 1 per 6 months
Chinstrap: 1 per 6 months
Disposable filter: 2 per 1 month
Washable filter: 1 per 6 months
Water chamber: 1 per 6 months
Note: Medicaid does not provide 90-day refills. Supplies will follow the above refill schedule.
NOTICE TO PHM PATIENTS:
If you wish to purchase additional supplies more frequently than your insurance allows, we suggest that you check competitive pricing on the internet. Suppliers with a Medicare/Medicaid supplier contract have variable requirements by plan that may limit our ability to provide additional items directly to patients. Internet suppliers are not restricted by these requirements.