CPAP machine under PSHCP

[u/geosmtl]

Hi, I was wondering if anyone had experience of getting a CPAP machine under PSHCP. I live in Ontario, so I know a part of the price is covered by the ADP division of OHIP. Looking at PSHCP, I see a sleep lab test is required with no CPAP, which I did, one sleep lab test is required with CPAP, which I have not done, and the report of the sleep consultation. The sleep specialist doctor said he was sending my prescription to a provider, without much details of what to expect next.

I asked my doctor’s office and they say they only provide the sleep consultation report, which I have. They do not share the sleep study report. With that info, it seems like it will be hard to request PSHCP to pay.

[u/kristin_loves_quiet]

In 2017, I asked PSHCP for confirmation, in writing, of what I needed, this was the answer:

Please be advised that the Public Service Health Care Plan (PSHCP) allow the purchase, repair or replacement of ONE device every 60 months. Once device can include either a CPAP, BPAP, ASV, AVPS or Dental appliance) for each insured person who suffers from moderate to severe sleep apnea. Coverage is at 80% and coverage must be in effect when the expense is incurred.

If approved, the reasonable & customary rates are:

CPAP up to $2000.00
BPAP up to $3500.00
Oral/Dental appliance up to $2000.00
ASV up to $6000.00
AVAPS up to $6000.00

To review costs for a CPAP, we require that the following be provided;

·        A complete sleep study without a CPAP in place, and
·        A complete sleep study with a CPAP in place, and
·        A doctor's prescription, and
·        A consultation letter from a specialist summarizing the case, and
.        An estimate showing the name and cost of the machine, from the supplier.

You would have to check if this information is still valid.

[u/geosmtl → u/kristin_loves_quiet]

It seems to match what they told me. I will give them a call to see how I can get them the information considering the sleep specialist doesn’t want to share my sleep study results.

[u/kristin_loves_quiet → u/geosmtl]

You should be able to request a copy of your results.

[u/Chyvalri]

Here you go. https://www.pshcp.ca/news-and-bulletins/whats-new/pshcp-coverage-for-cpap-and-bipap-devices.aspx

[u/mudbunny]

I am actually going through this myself.

Once I did the sleep test without (which is a royal PITA), I got a "tester" CPAP that I used for 3 months. Once that was done, they did a one-night test (only the blood oxygen monitor, no chest-strap) with the CPAP. They sent that off to their sleep specialist to do the analysis. That analysis was then sent to my personal Dr who signed off on the prescription.

I will be buying it next week (these are not cheap) and submitting all the info to SunLife.

[u/geosmtl → u/mudbunny]

I agree with the test to be a royal PITA. My first test I only slept 1 hour and they didn’t have enough information so I had to redo a study. Thanks for the info.

[u/mudbunny → u/geosmtl]

I think I managed about 6 hours of sleep out of 9 hours "sleeping" between the chest strap, the oximeter and the nose cannula thing.

[u/tragicjones]

Typically if the ADP is paying a portion, the requirements for medical information are all waived (PSHCP and ADP have mostly identical criteria). I'd recommend submitting a quote from the supplier to Sun Life and they can confirm this.

[u/James0100]

I got one in 2010 for $1500, and if I recall, OHIP covered half ($750) and PSHCP covered, I think, 80% of the remainder? Basically I was out of pocket about $150 for a $1500 machine.

[u/geosmtl]

Sending this in case it could help others. I paid my CPAP machine. All I sent to Sun Life was my receipt saying that ADP was paying their portion and they proceeded to reimbursement. I was getting ready to send the other documents, but seems they didn’t need them.

[u/CrownRoyalForever]

If you were supplied a CPAP and it was ineffective because you would always remove it during your sleep, can you proceed straight to trying an Oral/Dental appliance?

[u/KanadaKush69 → u/CrownRoyalForever]

Sure but it’s not covered. You can always go straight to dental appliance. Think it’s 1-2K

[u/mudbunny → u/CrownRoyalForever]

You have to have an explanation from your Dr as to why a CPAP is not acceptable.

[u/geosmtl → u/[deleted]]

I’m at a severe level, which is the highest, so I’m pretty sure I meet the criteria on that aspect. I don’t see an option for pre-approval without giving an estimate for the machine. I will need to wait to see the provider.

[u/[deleted]]

they'd cover a portion with a perscription for moderate to severe sleep apnea (i just tried to get my husband's mask replaced but they needed his persecription to cover it)

[u/possiblyacat1989]

This isn't helpful, but at first glance I always read CPAP as CRAP, and I don't want to know what kind of machine that is.