You’ve been diagnosed with sleep apnea and one of the first things on your mind is “How will I pay for the CPAP machine and supplies?” Usually this is followed by “Does my insurance cover CPAP?” and then “Can I get it cheaper online?”
If you’re one of the 22 million Americans who suffer from sleep apnea, these are the kinds of questions that can (literally) keep you up at night.
There’s some good news right off the bat; CPAP equipment is classified as “durable medical equipment.” Skipping over the boring insurance terminology, what this means for you is: most insurance providers (including Medicaid and Medicare) will not only cover your CPAP machine, but also the mask, filters, tubing, and headgear.
But your insurance coverage is subject to deductibles and copay, so buying your CPAP supplies from an online retailer like Amazon is the way to go, right? Hang on! You could be stepping over dollars to save yourself pennies! Read on to find out whether insurance or cash-pay will save you more money in the long run.
Before we get into the cost-saving details, we need to address the elephant in the room: CPAP compliance. Also known as CPAP adherence, compliance is the measurement of how often and how long you use your CPAP machine. If you want your machine covered by insurance (private or government) you’re going to have to demonstrate compliance.
“They want to look at the compliance information to make sure that the patient is using the machine so they will pay for future CPAPs and for future CPAP supplies." <strong>- Megan Roberts, Respiratory Therapist and CPAP Clinician at Aeroflow Healthcare</strong>
The bottom line is that CPAP equipment can get expensive, and insurers want to make certain that you’re actually going to use it before they shell out.
The exact requirements differ from company to company, but a common goal is to see you using your CPAP for at least four hours per night for 30 consecutive days during the first three months of use. Some plans may then require a face-to-face appointment with your doctor following the compliance period.
If you’re concerned about meeting your policy’s specific requirements, Aeroflow’s sleep coaches can help you understand your compliance goals and provide solutions that make adjusting to CPAP therapy as easy as possible.
Does Insurance Cover CPAP?
Most private insurance companies– think BlueCross BlueShield or United Healthcare– will cover CPAP machines and supplies. Even better, they’ll likely cover a regular schedule of replacement supplies throughout the year!
To qualify, your insurance company will require a prescription as well as a compliance period.
The flipside to using your insurance is that the amount you end up paying depends on the specifics of your deductible, copay, and/or coinsurance.
You’re going to end up paying out of pocket until you reach your deductible.
Because of this, many people seek discount or cash-pay options, but that could be costing them in the long run!
With normal use, many of these parts will become worn, cracked, or dirty. If you buy your CPAP supplies without insurance, you’ll be responsible for the full cost of the replacements.
But if your medical costs (including your CPAP machine and supplies) will exceed your deductible for the year, these replacement parts will then be heavily discounted or possibly even free!
Note: Your policy probably won’t cover extras like CPAP sanitizers, removable batteries, or back-up equipment, and buying them probably won’t contribute toward your deductible. For these items, an online CPAP retail store like CPAPSupplies.com may be your best option!
In a moment, we’ll show you how to use your manufacturer’s replacement schedule to calculate whether insurance or cash-pay makes the most sense for you. If you’re not enrolled in Medicare or Medicaid, you can skip directly to the section about buying CPAP without insurance.
Does Medicare Cover CPAP?
Medicare will cover 80% of the costs associated with your CPAP therapy if you meet their requirements, but there’s a catch that surprises many people.
For the first 13 months of use, Medicare will only pay your supplier as a rental. After the rental period ends, you will own the machine just like a direct purchase, but until then your Part B deductible will apply.
To meet their requirements you must:
- Have a face-to-face appointment with a physician that results in a diagnosis of sleep apnea.
- Have a prescription for CPAP therapy.
- Complete a 90 day compliance period, using the machine at least four hours per night for a minimum of 70% of the first 90 days.
- Meet with your physician once more between the 31st and 90th day to document that the CPAP therapy is helping.
Note: Medicare will require you to purchase your equipment from a Durable Medical Equipment (DME) supplier, and will only cover your machine and supplies if your doctor AND your DME supplier are enrolled in Medicare.
If you have a Medicare supplemental plan, be sure to provide that information when speaking to your Aeroflow Sleep specialist as it could lower your costs even further!
Does Medicaid cover CPAP?
Generally, Medicaid will cover CPAP machines, however the supplies may be another story. Each state manages its own Medicaid plan individually, so CPAP coverage varies from state to state.
You should check your state Medicaid coverage directly for specific benefits and authorization rules.
That said, most Medicaid plans follow Medicare coverage guidelines, so there are a few requirements you can bank on. Most will require prior authorization and a face-to-face appointment with your physician even if you’re already a current CPAP user. A prescription and a compliance period will also be required.
After your doctor has approved your supplies as medically necessary, a request will be sent to your Medicaid insurance provider for review. If this review is required in your state, no supplies can be sent until it is approved.
Your deductible and/or copay may apply. If Medicaid is your secondary insurance, you should inform your Aeroflow Sleep specialist of both your primary and secondary when providing your payment information. Your secondary insurance might cover the additional costs!
Can I Buy a CPAP Cheaper Without Insurance?
Can you find great cash-pay deals on new CPAP machines? Yes!
Will it be cheaper in the end? That depends...
Many DMEs and online retailers offer discounts for those who may not have– or choose not to use– their insurance. You may find the up-front price of a CPAP machine significantly cheaper than your out-of-pocket costs with insurance, but that’s not the only cost to consider.
You’ll still need a prescription from your physician, but you’ll bypass any compliance or rental requirements!
You’ll also find more flexibility in choosing your equipment. Since you won’t need to worry about restrictions on reimbursement, you’ll have a wider selection to choose from. The only preauthorization you have to worry about is your own say-so.
On the other hand, you’ll be fully responsible for the cost of any future replacement supplies. Over time your mask will wear down, your headgear will stretch, and bacteria can build up in your filters. Even reusable filters should be replaced every six months. If you bought your machine and supplies through a cash-pay retailer, these purchases won’t contribute toward your deductible.
How to Use Your CPAP Supplies Replacement Schedule
For the most effective therapy, CPAP manufacturers provide a recommended replacement schedule on certain parts and supplies.
Here’s the trick to getting the best price on those parts: you need to compare your replacement schedule against your deductible and out-of-pocket maximum.
Let’s assume you have a $3,000 deductible. If you were to purchase a new machine in January, then followed Medicare’s CPAP replacement schedule, you’d hit your deductible by July!
And that doesn’t even include any doctor visits, procedures, or the cost of the sleep study itself.
CPAP Supplies through Aeroflow Sleep
Sleep apnea shouldn’t keep you from a good night’s sleep and neither should paying for CPAP. No matter what payment option you choose, Aeroflow Sleep can assist you at every step.
If you need help understanding your insurance coverage, an Aeroflow Sleep specialist can discuss your CPAP benefits and compliance requirements.
Or, if cash-pay is the smarter choice for you, we’ll discuss the best deals for your money.
Either way, we connect directly with your doctor to handle all the details. When you’re ready to order, we’ll match you with the perfect CPAP machine, while trained clinicians help you adjust your mask fit and machine settings.
Even after you’ve ordered, Aeroflow Sleep patients can schedule a one-hour phone call with a clinician to make sure you get the best rest possible. Additionally, Aeroflow Sleep Coaches are also available as a resource to get you through the compliance period.
Talk to Aeroflow Sleep about the most affordable options today.
CPAP Insurance Glossary
Health insurance premium - The monthly rate you pay your insurance company
Deductible - The amount of medical costs you must pay before insurance coverage begins
Copay - A fixed charge paid by you for a specific medical expense (i.e. doctor’s visit, prescriptions, ect.)
Coinsurance - A percentage of a medical cost paid by you after your deductible is met
Information provided on the Aeroflow Healthcare blog is not intended as a substitute to medical advice or care. Aeroflow Healthcare recommends consulting a doctor if you are experiencing medical issues or concerns.