Most people diagnosed with sleep apnea are usually bothered about the cost of the CPAP machine and supplies. Another thing that bothers them is if CPAP is covered by their insurance and whether they can get it cheaper online.
According to statistics, twenty million Americans suffer from sleep apnea and if you are one of them, these things will certainly play on your mind from time to time.
Thankfully, CPAP equipment is classified as “durable medical equipment” and this implies that it will be covered by most insurance providers (this includes Medicaid and Medicare). These insurance providers will also cover the cost of filters, headgears, masks, and tubing.
However, what your insurance package covers is still subject to deductibles and you may be tempted to purchase CPAP supplies from an online outlet such as Amazon. Oh! Well, to be sure that your copay or insurance will save you some money in the long run, continue reading.
CPAP Compliance
We cannot talk about cost without first discussing CPAP compliance which is sometimes called CPAP adherence. By compliance, we are referring to the rate or frequency of use of your CPAP machine. Your machine will not be covered by insurance if you cannot prove that you have been compliant to an extent. Insurers just want to be sure that the patient makes use of the CPAP machine from time to time. Due to the relatively high cost of these machines, insurers want to be very sure that you’d make use of it before shelling out.
The requirements are not the same for all companies. Nonetheless, they all require that you use CPAP machine for a minimum of four hours per night for a 30-day period during the first three months. Under some arrangements, a face-to-face meeting with the doctor or physician may be required during the compliance period.
If you’re unsure you tick all the boxes required by your health insurer, talk to a sleep coach so that your compliance goals can be scrutinized and properly analyzed.
Does insurance really cover CPAP?
A vast majority of insurance companies and providers in the United States of America provide cover for CPAP machines and supplies. They even go to the extent of covering replacement supplies throughout the year.
Your insurance provider will typically request for a period of compliance and a prescription. Summarily, the total amount you’d eventually pay to your insurer depends on the details of your copay, deductibles, and/or coinsurance.
Is CPAP covered by Medicare?
Medicare will cater for 80% of the total cost of your CPAP therapy if you meet what is required. However, some things need to be clarified.
To start with, for the first year and one month, the supplier will only receive payment from Medicare as a rental. This means you will not own the machine until the end of the rental period. It will be like a direct purchase and that is when your direct deductible will start to apply.
You must do the following to meet with their requirements:
- Have a physical consultative session with a physician or doctor that confirms that you are diagnosed with sleep apnea.
- A prescription for CPAP therapy must be in place.
- 3 months period of compliance must have been completed and the machine should have been used at least four hours every night for a minimum of 70% of these 3 months.
- Have a consultative session and meeting with your physician one more time between the 31st and 90th day. This is so that confirmatory documentation is in place to verify that the therapy is effective.
You will be required by Medicare to purchase the equipment from a Durable Medical Equipment (DME) supplier. However, Medicare will only cover the cost of the machine and supplies if your chosen DME supplier and doctor are under their scheme.
Is CPAP covered by Medicaid?
While Medicaid may cover the machine cost, it is not certain that the cost of supplies will be covered. The approach to Medicaid plans differs from state to state. Therefore, CPAP coverage is not the same across states. For certainty and clarity, check out your state’s Medicaid coverage.
Nonetheless, Medicaid plans closely follow Medicare coverage guidelines. So, there are so many similarities in terms of requirements. Typically, a face-to-face appointment with a doctor and prior authorization are part of the requirements regardless of whether you are a current CPAP user or not. Other common requirements are a prescription and period of compliance.
Your Medicaid insurance provider will receive a request as soon as the doctor has confirmed that the supplies are medically necessary. If in your state review is needed, it must first be approved before any supply is sent.
Is it possible to purchase a CPAP cheaper without insurance?
It is not impossible to get impressive cash-pay deals on new CPAP machines. However, whether it will be cheaper in the end depends on a host of factors. If you choose not to use your insurance, you may just be eligible for some of the discounts offered by some DME’s and online retailers. The out-of-pocket insurance cost may even be higher than the CPAP machine’s upfront cost but there are some other costs to consider.
Pros:
A prescription from your doctor is still a requirement but there will be no need to fulfill any rental or compliance requirements. You also have flexibility in equipment selection because there is no restriction on reimbursements. You can select from a wide array of options.
Cons:
You will have to pay for any future replacement supplies. Items like masks, headgears, and filters are susceptible to wear and tear.
How to use the replacement schedule of your CPAP supplies
To improve therapeutic effectiveness, manufacturers of CPAP curated a replacement schedule for important supplies and parts. To get the best price on these parts, do a comparison of your replacement schedule against your deductible.
CPAP insurance glossary
Health insurance premium – This is the rate you pay to your insurance provider on a monthly basis.
Deductible – This is the total medical cost that must be covered before insurance coverage kicks in.
Copay – This is a fixed sum you pay for a particular medical expense.
Coinsurance – This is a percentage of medical cost you pay after deductible.