Medicaid unbundles CPAP payments in NY

ALBANY, N.Y. – With increased costs and surcharges weighing on providers, the recent decision by New York state Medicaid to unbundle CPAP and BiPAP supplies is “a big win,” say stakeholders. 

“Anything we can do to level that playing field and unbundle those supplies – it’s added reimbursement,” said David Chandler, senior director of payer relations for AAHomecare and chair of NEMEP’s Payer Relations Committee, which worked with Medicaid officials to get the change implemented.  

Prior to June 1, when the new policy took effect, reimbursement for a CPAP device was $496.20 and a full-face mask was $143.21, including headgear tubing and filters, making the total for a new set-up $639.41. 

Unbundled, that total is $826.04, a gain of $186.63. 

“It’s a big win,” said John Quinlan, NEMEP president. 

Stakeholders told state officials that, with a large population of Medicaid recipients enrolled under managed care organizations, which can pay even less, access to CPAP therapy was at risk. 

“We had a call where we talked about the increased prices with CPAP and BiPAP and everything that’s going on and we told them we’re not going to be able to afford to provide Medicaid members with CPAP because of the costs and because they pay low rates,” said Quinlan. 

Adding to the squeeze: Some MCOs weren’t covering heated humidifiers, because the Medicaid manual didn’t clearly define whether they were included as part of a bundle or paid separately, says Quinlan. Even when they were paid for, heated humidifiers were typically down coded and paid at the rate for unheated humidifiers, representing a cut of about 50%, Quinlan says. 

“Not only is this a win for fee-for-service, but also Medicaid managed care organizations now have to pay for humidifiers,” he said.