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Does Insurance Pay for a CPAP Machine? (Coverage and Cost)

Jun 08, 2016
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Tamara Kaye Sellman, RPSGT, CCSH
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CPAP machine, CPAP equipment, CPAP mask, cpap

what does your insurance policy cover?

Just as with the costs associated with sleep studies, patients are equally concerned about the costs of buying and using positive airway pressure (PAP) therapies like CPAP, BiPAP, APAP, and ASV.

It may seem like there are a lot of "moving parts" in the CPAP therapy kit and each has its own lifespan for use.

Knowing ahead of time how much your health plan offers in the way of CPAP machine insurance coverage can help you make the best decisions about what to rent or buy, and how frequently you need to replenish your supplies.

Insurance and CPAP

The cost of a CPAP machine depends on too many variables to be meaningful here. New CPAP machines may have multiple prices, depending upon who you buy them from, whether you use insurance coverage for CPAP, and whether your provider offers CPAP supplies through a contracted suppliers network. There really isn't a single CPAP cost breakdown.

Most private insurance policies cover PAP therapy equipment, as it is categorized as durable medical equipment (DME).

Before you make any does your health insurance policy cover cpap and cpap supplies?purchases or rental agreements, you're best bet is to call your insurer to ask about coverage details.

Because you are purchasing or renting through durable medical equipment suppliers, you may discover that your deductibles and copays for your PAP therapy may vary from your usual and customary policy payouts. You may also need to seek pre-authorization by your payer.

In addition, you are purchasing a machine, a mask, and supplies which require replenishment or replacement as they wear out. Your insurance carrier should be specific about what it will reimburse for and how frequently.

This includes claims for new and replaced CPAP tubing; CPAP masks, mask parts, headgear, and chin supports; permanent and disposable CPAP filters; and CPAP humidification chambers.

Coverages for each of these separate elements of a CPAP kit may differ, depending upon your policy and whether you have secondary insurance coverage.

A word about PAP therapies: In this article, we refer to CPAP therapy, which is only one specific kind of PAP therapy. CPAP, BiPAP, APAP, and adaptive servo ventilation (ASV) represent the spectrum of DME known as noninvasive ventilation (NIV) devices. For simplicity's sake, we're referring to all PAP therapies in this article as CPAP, the most commonly prescribed PAP prescription.

Compliancenew cpap machine

Compliance is the buzzword for CPAP usage for good reason: If you don't use your CPAP, you aren't going to get better.

Sleep apnea is a problem that doesn't just come and go; like asthma, it requires a mechanical treatment to prevent it as well as to provide you with important relief from all the symptoms that come from untreated sleep apnea, such as hypertension, mood disorders, excessive daytime sleepiness, and more.

Compliance (also referred to as adherence) is the term doctors and insurance providers use when referring to how loyal you are in using your therapeutic device.

Minimum compliance for CPAP is defined as "at least 4 hours of use a night for at least 5 nights a week." In the long term, this is defined as 4 hours per night for at least 22 days out of a consecutive 30 days within a 90-day (3-month) period.

Why 4 hours a night? Research shows that 4 hours a night is the minimum amount of usage that can show improvements to cardiovascular health. 

cpap compliance is critical to success in treating sleep apneaThe "use it or lose it" dictum that comes with a CPAP prescription is no small thing. If your usage average runs below this definition of compliance, your doctor will inquire into your struggles with using it because they are concerned about you getting better. 

In addition, the Affordable Care Act now requires proof of compliance as a cost-savings measure.

Your insurance company will also be less likely to reimburse you for your equipment if you're not using it to the minimum requirement. CPAP equipment is expensive, and payers aren't interested in funding machines that are collecting dust in the closet. 

In order to monitor compliance, most machines now come equipped with modems or SD cards that collect data to show proof of usage. This data is either sent wirelessly or "read" off your machine or SD card by a DME technologist.

This isn't just a feature to satisfy insurance companies; your sleep specialist wants to know you are using your machine because they have a vested interest in improvements to your health. 

This is why it's critical that, once you receive your CPAP kit, you maintain regular contact with your sleep specialist and DME provider to ensure you are making the most of your therapy.

A quality sleep center will provide support and follow-up in multiple ways (email, phone calls, office visits, or support groups) to help you to solve any problems with using the mask or the machine. They are your best cheerleader for CPAP success and are skilled in troubleshooting problems and helping you overcome issues with therapy tolerance. Never hesitate to ask them for help if you feel you are struggling to make CPAP work for you.

Am I required to pay for CPAP with insurance? 

Not necessarily.

Purchasing your equipment outright through an in-network DME provider allows for some discounts, which could make your insurance coverage very useful in keeping your costs down.

Your costs will  vary depending upon the kind of device you  need: CPAP and APAP are less expensive than BiPAP or ASV, for instance, and  may require pre-authorization. But if you use insurance and go through an in-network provider, you could make out pretty well. cpap accessories like cpap tubing and cpap masks should also be covered by insurance

However, this depends entirely upon the kind of insurance you have. As mentioned in our previous article about insurance coverage for sleep studies, there is the "cash pay" those who have a catastrophic plan which does not cover much of your CPAP needs, or those who don't want to use their insurance to pay for their equipment.

As with the prices of sleep study services, there is more than one price for certain kinds of equipment: the price set by the insurance company contracted with your doctor, and the doctor's cash-only price, which is always discounted. Cash payment can be a very good option for savvy patients who notice the differences between insurance pricing and self pay.

Renting versus purchasing CPAP equipment

Insurance companies frequently use a "rent-to-own" approach, which helps you by applying your monthly payments to your machine toward its purchase until you have paid it off (usually between 3 and 10 months). The rental versus purchase option is predetermined by your insurance company; therefore, you and your doctor do not have a say in this payment structure.

However, one benefit of the rental option: If you don't like your machine after a couple of months, or your doctor decides to change your prescription or give you a different kind of machine, you are not out the entire cost of a fully purchased machine. Simply turn your current one in and get a new one.

For newer patients with complicated health concerns and who may expect to struggle with CPAP initially, this is good prevention against buying a machine outright that, two months later, might become relegated to the back of the closet. 

CPAP assistance program (CAP) american sleep apnea association

The American Sleep Apnea Association hosts the CPAP Assistance Program (CAP) which has provided more than 4,000 CPAP equipment kits to patients in need. In order to receive a kit, you need to have a valid prescription and must fill out an application to verify need.

Kits are considered free, but the ASAA asks for $100 payment to help them to keep the program open to all who need it. This is a significant savings over the total cost of CPAP kits even after insurance coverage. And, as one user expressed in a CPAP forum recently, "CPAP is still much cheaper that heart failure." 

Because the nonprofit relies on donations of machines, masks, and supplies, they may not have specific brands to choose from, and not all kinds of therapies may be available (such as ASV or BiPAP). The kits are offered “as is” and without warranty or technical support from the manufacturer. However, they do provide a 30-day warranty to cover damages caused during shipping or due to mechanical failure.

Despite the program's limitations, it's still a great opportunity for people who need CPAP but may not be able to afford it.

CPAP supplies Seattle Washington


Sources: 

American Sleep Apnea Association
National Sleep Foundation
VeryWell.com

 

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