Insurance Plans Plus Medicare and Medicaid Can Help Pay for Your CPAP Therapy. Here’s How to Make Sure You’re Covered!
“Is CPAP covered by insurance?” That’s a question we hear frequently.
Not surprising, since CPAP (continuous positive airway pressure) has been the treatment of choice for decades for sleep apnea, and sleep apnea affects more than 30 million Americans.
If untreated, it can lead to such serious health conditions as diabetes, heart disease, and high blood pressure (hypertension). But CPAP can be expensive based on the type of health insurance coverage you may have.
So it’s natural for people to ask, “Is CPAP covered by insurance?” The short answer is yes, usually! CPAP devices and certain supplies (such as masks, tubing, filters, and humidifiers) are generally covered by most health insurance plans, including Medicare and Medicaid.
Here’s what you need to know to make the most of your insurance coverage.
Qualifying for Coverage
Most insurance plans plus Medicare and Medicaid have specific requirements you need to meet to qualify for coverage for CPAP therapy.
You need a prescription
To provide coverage, insurers require proof that your CPAP device is medically necessary.
Your doctor must confirm that sleep apnea is causing your sleeping difficulties. First, your doctor will determine that you have common symptoms of sleep apnea, such as gasping for air while sleeping, difficulty staying asleep (insomnia), excessive daytime sleepiness (hypersomnia), and loud, chronic snoring.
The next step is to have a sleep study performed, where special equipment records your brain waves, oxygen levels, and heart rhythm as you sleep.
If the results indicate you have sleep apnea, your doctor will give you a prescription for a CPAP device, which needs to be updated annually.
According to the sleep study results, sleep apnea is classified as mild, moderate, or severe. Medicaid and Medicare partially cover CPAP devices for all three classifications. Other insurers have different standards, so be sure to check yours.
Proof of adherence
During the first few months, most insurance providers will only continue coverage if you provide evidence that you are complying with your CPAP therapy.
To demonstrate adherence, CPAP devices record and analyze your usage, which you can be used as proof of adherence. Most minimum adherence requirements are 4 hours per night every night.
Evidence that your symptoms are improving
Insurers may also require that you have a follow-up visit with your doctor to evaluate the effectiveness of your therapy. The doctor will then provide documentation that your symptoms are improving.
CPAP and Insurance Plans
If you meet the requirements, most insurance plans cover a significant portion of CPAP therapy.
Coverage and terms vary from insurer to insurer. Some reimburse you for the cost of purchasing your CPAP device. Others offer a “rent-to-own” plan where you pay a monthly fee; insurers generally share this cost with you. After the rental period, you own the CPAP device.
If the insurer decides that you aren’t adhering to your therapy, they can take back the CPAP device and not refund any rental fees you’ve paid.
CPAP and Medicare
Once you’ve qualified for coverage, paid the 20% deductible, and confirmed your doctor and CPAP provider are Medicare-enrolled, Medicare pays the remaining 80% for your CPAP machine and supplies if you meet certain requirements.
Medicare covers an initial 3-month trial period. If your doctor documents that you are complying with therapy, Medicare will make payments for the next 13 months. Then you’ll own the CPAP device.
If you had been prescribed CPAP therapy before you got Medicare and you meet specific requirements, Medicare may cover a rental or replacement CPAP machine and accessories.
If you stop using your device regularly, Medicare may stop paying the rental fee. You will have to return the device to the supplier or pay the remaining balance in full.
CPAP and Medicaid
Medicaid is an insurance program designed for people with limited economic resources. Every state administers its own program, so coverage varies. Check with your state’s Medicaid office to learn what is covered.
Generally, Medicaid programs follow the same guidelines and requirements as Medicare.
Paying Out of Pocket
Insurance plans often require that you first meet a deductible before they cover your CPAP device. But if the deductible is high, many people purchase the device out of pocket, which may offer some advantages:
- You own the machine outright
- You have a greater choice of devices—and potentially lower prices
- You don’t have to bother with the “rent-to-own” plan
- You avoid the initial trial period and the requirements of complying with therapy—and the possibility of being denied coverage
You still need a prescription from your doctor to purchase a CPAP device. And you will have to pay for the cost of your CPAP supplies and accessories.
Be Sure You’re Insured
Today, most insurance plans including Medicare and Medicaid help pay for your CPAP therapy when you meet their requirements for qualification. Compliance with therapy is critical since it helps reduce the risk of the harmful health consequences of sleep apnea.
Policies vary from company to company and state to state and are frequently updated, so be sure to contact your insurance provider or ask your doctor for assistance. And get the CPAP therapy—and coverage—you need!
References
1. Noyed, D. (Updated 2022, November 8). Does Insurance Cover CPAP? Sleep Foundation. https://www.sleepfoundation.org/cpap/does-insurance-cover-cpap.
2. Ikpeze, T. (Updated 2023, June 22). Does Insurance Cover CPAP? SleepApnea.org. https://www.sleepapnea.org/cpap/does-insurance-cover-cpap/.
3. Continuous Positive Airway Pressure (CPAP) devices, accessories, & therapy.
Medicare.gov. https://www.medicare.gov/coverage/continuous-positive-airway-pressure-devices.
4. Riva, M.M. (2023, October 24). A Guide to Medicare Coverage of CPAP Machines and Supplies in 2023. The National Council on Aging. https://www.ncoa.org/adviser/sleep/does-medicare-cover-cpap-machines/.
5. Does insurance cover sleep apnea therapy? ResMed. https://www.resmed.com/en-us/sleep-apnea/sleep-blog/does-insurance-cover-sleep-apnea-therapy/.
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