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Expected to Work/Barriers to Full Employment Policy & Procedures

Published Date: June 07, 2016
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10 Supplementary Health Benefits

Continuous Positive Airway Pressure (CPAP) Devices

AUTHORITY

ISTHB Regulation, Schedule 4, Section 27 and Delegation of Minister’s Authority to Directors/Staff Ministerial Order

INTENT

The Income Support (IS) program provides coverage for Continuous Positive Airway Pressure (CPAP) devices for the treatment of moderate to severe Obstructive Sleep Apnea when it is medically essential.

POLICY

The IS program may provide:

  • Up to $1,700 for a fixed pressure CPAP device, or
  • Up to $2,000 for an auto-pressure CPAP device.


The above prices include a CPAP device with a three year warranty, heated humidifier, hose, mask with headgear, chin strap (if needed), and 12 filters.

Replacement CPAP devices may be considered if the warranty has expired and the client confirms that their CPAP device is no longer working.  The IS program does not cover the cost of CPAP device rentals or repairs.

Notes
A Level 1 Sleep Study is conducted in a sleep lab or clinic.  The client requires a referral from their physician to have a Level 1 Sleep Study.  For additional information, see Alberta Health Services (AHS) Sleep Clinics for Edmonton, Calgary, and Lethbridge.

A Level 3 Sleep Study is a portable sleep study conducted in a person’s home.  The equipment required to conduct the sleep study is loaned to a person by an AHS sleep clinic or private vendor with instructions on how to use it.  The IS program does not provide funding for Level 1 or Level 3 sleep studies.

Clients who must travel to access a Level 1 or Level 3 Sleep Study may be eligible for funder under the Special Transportation and Travel Payment policy.

First CPAP Device

Clients requesting a CPAP device for the first time must have a confirmed diagnosis of moderate or severe OSA, complete a CPAP trial, and obtain a prescription for a CPAP device.  This is a two-step process where clients must demonstrate their diagnosis before proceeding to a CPAP trial.

First CPAP Device – Step 1 Substantiation

The IS Worker must not request substantiation documents from Step 2 until the Respiratory/Sleep Medicine Consultant confirms that it is safe to do so.  To proceed without the medical consultant’s advice could put the client’s life in jeopardy.

For their first CPAP device, the client must provide:

  • Pulmonary Function Test (PFT) is needed to check for severe lung disease and must include the client’s Body Mass Index (BMI).
    • The BMI from a Level 3 Sleep Study is not a substitute for a PFT.
  • Current medication list obtained from the pharmacy, and
  • Full Level 1 or Level 3 Sleep Study including the interpretation by a specialist sleep physician and all graphs, charts, and summaries that make up the study.  Sleep studies older than two years will not be accepted.
    • A Level 3 Sleep Study is not appropriate for everyone.  Clients with the following health concerns will require a Level 1 Sleep Study for their first CPAP device:
      • A BMI above 38,
      • A history or cardiac issues, or
      • Taking narcotic, psychoactive or other medications that affect sleep.
    • In addition, a Level 1 Sleep Study will be required when the Respiratory/Sleep Medicine consultant determines that a Level 3 Sleep Study is insufficient or that CPAP treatment may be unsafe.


First CPAP Device – Step 2 Substantiation

After reviewing the documents from Step 1, the medical consultant will ask the IS Worker to proceed to Step 2.  Substantiation documents from Step 2 must not be requested until the medical consultant confirms that it is safe to proceed.  To do so could put the client’s life at risk.

Note
A Level 1 Sleep Study is completed in a medically supervised lab and may include a CPAP trial as described in Step 2.  This is acceptable and there are no safety concerns with this practice.  Most safety concerns are related to Level 3 Sleep Studies and trials because they are not completed in a supervised environment.

For their first CPAP device, the client must provide:

  • The results of a recent (a or b)
    1. CPAP trial and a Level 3 Sleep Study conducted while the client is being treated with a CPAP device.
      • The CPAP trial must be at least 14 days long.
      • The Level 3 Sleep Study is conducted on the last day of the trial while the client is being treated with a CPAP device.
      • Tests older than 12 months will not be accepted.
    2. CPAP trial completed in a sleep lab as part of a Level 1 Sleep Study.
      • This test can be arranged by a physician, public sleep clinic or by a private vendor.
      • Tests older than 12 months will not be accepted.
  • A doctor’s prescription for a fixed pressure or auto-pressure CPAP device.  The prescription must clearly indicate “fixed” or “auto-pressure” CPAP device, and
  • A vendor quote detailing the total cost of the CPAP device specified in the prescription.
    • The quote must include a CPAP device with a three year warranty, heated humidifier, hose, mask with headgear, chin strap (if needed), and 12 filters.


Replacement CPAP Device

In most cases, requests for replacement CPAP devices are completed in one step.  As the client was previously diagnosed and successfully treated with a CPAP device, there are few safety concerns associated with unsupervised CPAP device use.

For replacement CPAP devices, the client must provide:

  • The results of a recent (a or b):
    1. Level 3 Sleep Study conducted while the client is being treated with a CPAP device.
      • At a minimum, the test must show oxygen saturations and heart rate while the client is being treated with a CPAP device.
      • This test takes one night to complete.
      • Tests older than 12 months will not be accepted.
    2. CPAP trial completed in a sleep lab as part of a Level 1 Sleep Study.
      • These tests can be arranged by a physician, public sleep clinic or private CPAP vendor.
  • A doctor’s prescription for a fixed pressure or auto-pressure CPAP device.  The prescription must clearly indicate “fixed” or “auto-pressure” CPAP device, and
  • A vendor quote detailing the total cost of the CPAP device specified in the prescription.
    • The quote must include a CPAP device with a three year warranty, heated humidifier, hose, mask with headgear, chin strap (if needed), and 12 filters.
  • When possible, clients who did not receive their first CPAP device from the Income Support program, should also provide their original Level 1 or Level 3 Sleep Study including the interpretation by a specialist sleep physician and all graphs, charts, and summaries that make up the study.
    • This test would have been conducted just before the client received their first CPAP device.  It may not be possible for all clients to provide this information.

When necessary, the Respiratory/Sleep Medicine Consultant will ask for additional information or testing to confirm the client’s continued medical need for a CPAP device and to ensure that CPAP therapy continues to be safe and effective.

PROCEDURE

First CPAP Device

  1. The IS worker submits all required documents from Step 1 to CSS.AISHPerBenefits@gov.ab.ca or by fax to 780-644-3299 (email is preferred).  The email or fax coversheet must include:
    1. The client’s name
    2. File number,
    3. Whether a CPAP device has been provided in the past, 
    4. Whether the client or their cohabitating has an employer health plan or private insurance, and
    5. The contact information of the client’s IS Worker.
      1. Contact information for the client’s IS worker is critical for faxes.  Without it, it is impossible to return a recommendation from the medical consultant.  Faxes without an IS Worker’s name and phone number will not be reviewed.
  2. The medical consultant reviews the documents from Step 1 and provides an expert medical opinion on the safety and effectiveness of CPAP.  Based on the documents provided, the medical consultant will:
    1. Recommend the IS Worker request documents from Step 2,
    2. Request additional or missing information, 
    3. Advise that CPAP is unsafe, or
    4. Advise that CPAP is safe and all documents have been provided.  This may happen when the client has a Level 1 Sleep Study and submits Step 1 and Step 2 documents at the same time.
  3. Based on the medical consultant’s recommendation, the IS Worker makes a decision or requests more information from the client or vendor.
  4. If the medical consultant advises the IS Worker to proceed to Step 2 or requests additional information, the IS Worker:
    1. Contacts the client or vendor to request the information,
    2. Once received, the IS Worker sends the requested information to CSS.AISHPerBenefits@gov.ab.ca or by fax to 780 644 3299 (email is preferred).  The email or fax cover sheet must include the client’s name, file number, and IS Worker’s contact information.
  5. After all Step 1 and Step 2 documents have been reviewed, the medical consultants will provide a recommendation to approve or deny the request.  The IS Worker reviews the recommendation and makes a decision.
    1. If the decision is to deny the request, the IS Worker must contact the client to explain the reason for the denial.  Clients with additional questions should be directed back to their physician.
    2. If the decision is to approve the request, the IS Worker must notify the client and vendor of the approval.
      1. The IS Worker informs the client and vendor that the approved amount includes a fixed or auto-press CPAP device with a three year warranty, heated humidifier, hose, mask with headgear, chin strap (if needed), and 12 filters.
      2. The IS Worker issues payment for a CPAP device directly to the client or with an EMP 0018 Purchase Authorization and Invoice form.
      3. The IS Worker issues the benefit using LISA need code 1912 Medical/Surgical Supplies.


Replacement CPAP Device

  1. The IS worker submits all required documents from to CSS.AISHPerBenefits@gov.ab.ca or by fax to 780-644-3299 (email is preferred).  The email or fax coversheet must include:
    1. The client’s name
    2. File number,
    3. Whether a CPAP device has been provided in the past, 
    4. Whether the client or their cohabitating has an employer health plan or private insurance, and
    5. The contact information of the client’s IS Worker.
      1. Contact information for the client’s IS worker is critical for faxes.  Without it, it is impossible to return a recommendation from the medical consultants.  Faxes without an IS Worker’s name and phone number will not be reviewed.
  2. The medical consultant reviews the documents and provides an expert medical opinion on the safety and effectiveness of CPAP.  Based on the documents provided, the medical consultant will:
    1. Request additional or missing information,
    2. Advise that CPAP is unsafe, or
    3. Advise that CPAP is safe and no further information is required.  
  3. Based on the medical consultant’s recommendation, the IS Worker makes a decision or requests more information from the client or vendor.
    1. If additional information is requested, the IS Worker forwards the information to CSS.AISHPerBenefits@gov.ab.ca or by fax to 780-644-3299 (email is preferred).  The email or fax coversheet must include the client’s name, file number, and IS Worker’s contact information. 
  4. After all necessary documents have been reviewed, the medical consultants will provide a recommendation to approve or deny the request.  The IS Worker reviews the recommendation and makes a decision.
    1. If the decision is to deny the request, the IS Worker must contact the client to explain the reason for the denial.  Clients with additional questions should be directed back to their physician.
    2. If the decision is to approve the request, the IS Worker must notify the client and vendor of the approval.
      1. The IS Worker informs the client and vendor that the approved amount includes a fixed or auto-press CPAP device with a three year warranty, heated humidifier, hose, mask with headgear, chin strap (if needed), and 12 filters.
      2. The IS Worker issues payment for a CPAP device directly to the client or with an EMP 0018 Purchase Authorization and Invoice form.
      3. The IS Worker issues the benefit using LISA need code 1912 Medical/Surgical Supplies.