Does Insurance Cover CPAP Machine, Mask, and Supplies?
Does Insurance Cover CPAP Machine, Mask, and Supplies?
After a sleep apnea diagnosis, the first question many ask is how am I going to pay for my CPAP machine, mask, and supplies. The good news is, many insurance companies cover part or all of the cost. CPAP equipment is classified as “durable medical equipment” which means that most insurances including Medicaid and Medicare will cover the CPAP machine, mask, and supplies.
Insurance plans usually have deductibles and copays, so while the CPAP machines and supplies may require some out of pocket cost, they are generally less expensive to get through insurance than through an online retailer.
In order to get your CPAP machine, mask, and supplies covered by insurance, you have to demonstrate compliance. This means that you have to show proof of how often and how long you use your CPAP machine. Due to the expensive nature of CPAP machines, masks, and supplies, insurance companies want to see you’re going to use it before making the purchase.
Each insurance company has different requirements, but generally they want to see you use your CPAP for at least four hours a night for 30 consecutive days during the first three months of use. If your insurance company decides you are not using the machine as much as they’d like per your policy, they may stop covering their portion of the cost.
It is also important to note that if you decide to stop CPAP treatment and decide later you would like to try it again, your insurance company may require you to re-qualify for coverage. This includes doing another sleep study and getting a new prescription for a CPAP machine.
Does Insurance Cover CPAP?
Private insurance companies usually cover CPAP machine, mask, and supplies including a regular schedule of replacement supplies throughout the year.
Your insurance company will require a prescription and compliance period to justify the cost. You will still need to pay your deductible, copay, and/or coinsurance. You will have to pay out of pocket until you reach your deductible.
The machine itself can cost hundreds to thousands of dollars and the supplies will need to be replaced. Each provider has its own replacement guidelines.
Once you reach your deductible, the replacement parts become heavily discounted or possibly even free!
Does Medicare Cover CPAP?
Medicare considers CPAP machine, mask, and supplies to be durable medical equipment and provides 80% coverage under Part B as long as certain conditions are met.
For the first 13 months of use, Medicare will only pay your supplier as a rental. After that rental period is over, you own the machine outright, but until that’s true, the Part B deductible will apply.
To meet the Medicare requirements, you have to:
- Meet with a physician that diagnoses you with sleep apnea
- Obtain a prescription for CPAP therapy
- Complete a 90 day compliance period including using the machine for four hours per night for at least 70% of the first 90 days
- Have an appointment with your physician between the 31st and 90th day of treatment
Another Medicare requirement is you will be required to purchase your equipment for a durable medical equipment supplier, and Medicare will only cover your machine, mask, and supplies if your doctor and durable medical equipment supplier are enrolled in Medicare. (Insurance Covered CPAP is a durable medical equipment supplier who is enrolled in Medicare).
Does Medicaid Cover CPAP?
Generally, state Medicaid programs follow the same guidelines as Medicare. However, each state has its own Medicaid plan so CPAP coverage will vary state to state.
Medicaid does generally follow Medicare so there are a few things you can count on. Most Medicaid plans will require prior authorization, an appointment with your doctor, a prescription, and a compliance period.
Once your doctor has approved your medical need for CPAP, they will send a request to your Medicaid provider to review. Often Medicaid will provide CPAP coverage for a 12-week trial and only continue coverage if your sleep apnea improves during this time period and you meet compliance requirements.
Can I Buy a CPAP Cheaper Without Insurance?
Depending on the CPAP machine you need, the price can vary widely. The average cost is somewhere around $500-$800, however a BiPAP machine can start around $1,300. Then there is the cost of the humidifier, mask, hose, and replacement supplies.
If you choose not to use insurance, you still need the prescription but you don’t need to worry about compliance. You’ll also have more flexibility in choosing your equipment.
However, if you don’t use insurance you’ll be fully responsible for all the replacement supplies going forward. Over years, this can really add up.
How to Use Your CPAP Supplies Replacement Schedule
For the most effective CPAP treatment, you will need to replace supplies as they wear out. If you want to get them through insurance, you should compare your replacement schedule against your deductible and out-of-pocket maximum.
If you have a $3,000 deductible and purchase a new machine in January, then follow the Medicare CPAP replacement schedule, you will hit your deductible by mid-year.
CPAP Supplies Through Insurance Covered CPAP
At Insurance Covered CPAP, our goal is to help you get a better night’s sleep in the most cost-effective way possible. We are here to help you through the process including understanding your insurance coverage and walking you through compliance requirements.
We can help you find the perfect machine and get you set up so your insurance covers your replacement supplies.