People with obstructive sleep apnea experience partial or complete closure of the upper airway during sleep, which can lead to snoring, gasping, or even choking. If you’re in the 2% to 9% of adults with obstructive sleep apnea, a cpap machine may be the solution for better sleep.
A cpap (continuous positive airway pressure) machine sits next to your bed while you sleep. The machine is attached to a mask that fits over your nose, mouth, or both, and delivers pressurized air throughout the night to keep your airway open. Once cpap therapy is prescribed, your doctor will encourage you to use the machine every night for best results.
Reading: How much is a cpap with insurance
cpap therapy is effective, but it can also be expensive. Typical prices for CPAP devices range from $250 to $1,000 or more, not including the cost of necessary accessories such as filters and masks. If you’re considering starting CPAP therapy, you may be wondering if you can offset some of this cost with your insurance plan.
We will cover some of the most common insurance policies related to cpap equipment. These policies may be updated from time to time, so always check with your insurance provider for the most up-to-date information.
does insurance cover cpap equipment?
Most insurance plans partially cover the cost of cpap machines and related equipment. Often the machines themselves are covered to some extent, but you may be responsible for other components, such as tubing. replacement parts are sometimes covered, with a limit on the number of replacement parts that can be purchased annually. many insurance providers require that you meet your annual deductible before they will cover your cpap equipment.
Insurance providers often take your apnea-hypopnea index (AHI) into account when determining your eligibility for cpap therapy coverage. your there is the average number of partial or total cessation events you experience per hour. To determine your AHI, you must undergo a sleep study at a sleep lab or at home using home testing equipment.
Sleep apnea is classified as mild, moderate, or severe, depending on what you read. an ahi between 5 and 15 is considered mild, an ahi between 15 and 30 is moderate, and an ahi greater than 30 is severe. Medicaid and Medicare partially cover cpap machines for all three rates out there, as long as you meet certain conditions. other insurance providers may have different standards. Be sure to check your insurance policy to determine your specific requirements.
insurance compliance and prescription requirements
Before most insurance providers will pay for your cpap equipment, you must meet two requirements. First, you must have a prescription for CPAP therapy from your health care provider. Second, you must successfully complete a period of compliance with the cpap machine, to show that you are using the treatment regularly.
In order to prescribe a cpap machine, your doctor must confirm that your sleep difficulties are caused by sleep apnea and not by another condition. Your doctor will first check for symptoms of obstructive sleep apnea, including:
- loud snoring at night
- gasping or snorting during sleep
- excessive daytime sleepiness
- pains headache
- drowsiness or falling asleep while driving
If your symptoms indicate you might have obstructive sleep apnea, the next step is to have a sleep study. Doctors can test for sleep apnea with an overnight laboratory sleep study, also called a polysomnogram, or with a home sleep study. After reading and interpreting the results of your sleep study, your doctor can diagnose sleep apnea and work with you to develop a treatment plan.
to be eligible for reimbursement, center medicaid and medicare (cms) require proof that you are using the cpap machine at least 4 hours per night, 70% of the nights, in a period of 30 consecutive days . most machines log your usage for you. Some machines connect to an app on your phone and transmit usage information, while others use an SD card reader to collect the data. If you are unable to meet these requirements within the first 3 months, you may need to start the process all over again.
While these are the most common prescription and compliance requirements for cpap coverage, each provider has their own specific rules. check your policy for the specific requirements of your insurance provider.
safe and cpap machines
the terms of your cpap machine, insurance coverage depends on your provider. some vendors reimburse you for the cost of purchasing the machine outright, while others require a lease-to-own plan whereby you must use the machine for a set period of time before you own it.
Costs to buy a machine outright can range from $250 to $1,000 or more, depending on where you live and the type of machine you need. most cpap machines cost between $500 and $800. bipap machines, which provide a different level of air pressure for exhalation and inhalation, often cost thousands of dollars.
If you have a rent-to-own structure, your monthly fee is generally equal to the cost of the cpap machine divided by the number of months rented. Your insurance provider usually splits this cost with you, and the exact amount you pay depends on your policy. Please note that if you must rent for more than one year, you may have to pay a second deductible.
If your insurance company determines that you are not using the machine often enough under your policy, they may stop covering your portion of the machine rental. You need to decide if you prefer to pay the full monthly rental cost, buy the machine outright, or stop cpap treatment altogether.
Please note that if you decide to stop cpap treatment and then decide you want to try again, your insurance company may require you to requalify for coverage. This process involves performing another sleep study to receive a new diagnosis of sleep apnea and another prescription for a cpap machine. necessary doctor appointments and sleep studies have their own costs, depending on your insurance plan and associated deductible.
insurance and cpap supplies
When starting cpap treatment, the biggest initial cost is the cpap machine itself. then there are supplies that need to be replaced over time, including:
- mask components
- chin straps
- head harness
- water chamber
the costs of each component vary. the filters, which need to be replaced frequently, cost between $5 and $30 each. masks often cost $100 or more, and other gear ranges from $20 to $100. some rental plans may include the cost of replacement equipment, which is something to consider when comparing the cost of buying outright versus taking out insurance.
many insurance providers use medicare guidelines for equipment replacement:
however, each vendor has their own replacement guidelines. Among state Medicaid programs, 51% adhere to these guidelines, but 39% allow less frequent replacement of cpap equipment. only 10% allow for more frequent replacement.
secure accessories and cpap
As you adjust to cpap treatment, you may want additional accessories for a more comfortable sleep and easier travel. There are a number of optional accessories that you can purchase for your CPAP machine. these include:
- cpap pads, which are cut to accommodate the machine and tubes and allow you to move around at night.
- cpap wipers, that can help sanitize your machine and extend its life.
- mask liners that can absorb moisture and ensure a tighter seal to keep the mask in place.
- hose holders to help the cpap machine feel softer against the body and have a less medical appearance.
- cpap batteries, which are convenient for traveling when you don’t have access to a power outlet.
- travel bags, so you can pack your cpap equipment when you’re on the go.
In general, insurance does not cover any products that are considered optional. the costs of these products can vary depending on the quality. more expensive accessories often come with 1-3 year warranties.
does medicare cover cpap?
medicare considers cpap devices to be durable medical equipment and provides 80% coverage under part b, provided you meet certain conditions. Your doctor must first diagnose obstructive sleep apnea after an approved lab sleep study or home sleep study, and give you a prescription for a cpap machine.
then, medicare covers an initial 12-week period of cpap therapy for obstructive sleep apnea, as long as you meet the following requirements:
- has an hourly AHI between 5 and 14 and a comorbid condition related to obstructive sleep apnea, including hypertension, history of stroke, heart disease, excessive daytime sleepiness, insomnia, mood disorders and cognitive impairment; or
- has an hourly ahi of 15 or more.
You must also meet Medicare compliance requirements, which state that you must use the machine at least 4 hours per night, 70% of the time or more, for the first 3 months. if you do not meet these requirements, you must start the process over. this involves completing another sleep study, either in a lab or at home, and getting another prescription from your doctor.
if cpap therapy helps improve your sleep apnea symptoms during the 12-week period, medicare continues to cover the cost of your cpap equipment. With original Medicare coverage, you pay 20% of the machine rental plus the cost of supplies, like the cpap mask and tubing. Once you meet your Medicare Plan B deductible, Medicare pays for 13 months of machine rental if you use it continuously. once the 13 months are up, you own the machine.
does medicaid cover cpap?
State Medicaid programs generally follow the same guidelines as Medicare. You need a sleep test, a diagnosis of obstructive sleep apnea, and a prescription from your doctor. your there must also meet the same requirements as for medicare:
- index there between 5 and 14, along with a comorbidity related to obstructive sleep apnea; or
- there of at least 15.
if you meet these requirements, then medicaid provides cpap coverage for a 12-week trial. coverage continues if your sleep apnea improves with cpap treatment. You must also meet the same compliance requirements as Medicare beneficiaries, ie use the machine for at least 4 hours every night 70% of the nights.
pay out of pocket for cpap equipment
Insurance plans can significantly help defray the cost of a cpap machine. However, if your plan has a high deductible, you may be tempted to purchase your cpap equipment on your own and avoid your insurance. You may be able to find direct-to-vendor cpap manufacturers with lower prices than those available through your insurance plan, though be sure to check to see if these devices are FDA-approved.
When making your decision, consider whether your cpap equipment is likely to cost more than your deductible, both now and in the long run. don’t forget to budget for the ongoing costs of tubes, filters, and other replacements.
Keep in mind that whether you use insurance or not, medical equipment sellers require a cpap prescription so you can purchase the machine and equipment. this means your doctor still needs to perform a sleep study to make a diagnosis. Once you have the prescription, you can choose whether to buy your cpap equipment outright or go through your insurance plan. When you choose to purchase your cpap equipment without insurance, you can skip the rent-to-own process and own your machine right away. you also avoid treatment compliance assurance requirements. this eliminates the possibility of having to return your machine and restart the process of getting a sleep test and prescription from your doctor.
Another advantage of paying directly to a medical equipment supplier is the wider variety of products available to you. When shopping with an insurance provider, you are restricted to the providers that are covered by your insurance. this limits your coverage options and you may not get the exact product you want. Paying directly for your equipment gives you the opportunity to compare products and choose the cpap equipment that feels right for you.
frequently asked questions
We will answer some of the most frequently asked questions about cpap machines, equipment, and insurance coverage.
How often does insurance cover cpap machines?
Most insurance plans offer partial coverage for cpap machines once you meet your deductible. medicare participants are responsible for paying their deductible, plus 20% of the machine rental. If you have a high deductible on your health insurance policy, you may inadvertently end up covering the full cost of your cpap machine.
how much will i pay for cpap equipment?
prices for cpap machines start around $250 and can go up to $1000 or more. more advanced machines tend to cost more. the cost you pay depends on your insurance coverage.
In addition to the cpap machine itself, you also have to pay for additional equipment such as filters, which cost between $5 and $30, and masks, which can cost up to $100. most other kits range from $20 to $100.
does my deductible apply to cpap equipment?
Generally, your deductible applies to essential cpap equipment, not including optional accessories. Most providers have replacement schedules for components such as tubes, masks, and filters that indicate how often replacements are covered. if you need more frequent replacements for certain components, those costs may be out of pocket.
Will insurance pay for sleep studies for sleep apnea?
Most insurance plans cover a portion of the cost of your sleep studies, including studies done in a sleep lab or at home. You generally need a referral for a sleep study to be covered. your doctor must determine which type of study is right for you. Insurance providers almost always require that you present a diagnosis of obstructive sleep apnea before coverage for a cpap machine and related equipment begins.