Does Insurance Cover CPAP Machines?

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How Does Insurance for CPAP Machines Work?

Most insurance plans partially cover the costs of CPAP machines and related equipment. The machines are often covered to an extent, but you may be responsible for other components such as tubing. Replacement parts may be covered with a limit to how many parts can be purchased annually. Many insurance providers require you to meet your annual deductible before covering your CPAP equipment.

Insurance providers typically take your apnea-hypopnea index (AHI) into consideration when determining your eligibility for CPAP therapy coverage. Your AHI is the average number of partial or complete breathing cessation events you experience per hour. To determine your AHI, you must undergo a sleep study in a sleep lab or take a home sleep test (HST).

Sleep apnea is classified as mild, moderate, or severe, depending on the AHI reading Trusted Source Medline Plus MedlinePlus is an online health information resource for patients and their families and friends. View Source . An AHI of 5 to 15 is considered mild, 15 to 30 is moderate, and greater than 30 is severe. Medicaid and Medicare partially cover CPAP machines for all three AHI indexes, provided you meet certain conditions Trusted Source Medicare.gov Medicare.gov provides essential information about signing up for and using Medicare, which is health insurance for people 65 or older. View Source . Some insurance providers follow different standards. Be sure to check your insurance policy to determine specific requirements.

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What Do I Need to Get Insurance to Cover My CPAP Machine?

Before most insurance providers will pay for your CPAP equipment, you must fulfill two requirements Trusted Source American Academy of Sleep Medicine (AASM) AASM sets standards and promotes excellence in sleep medicine health care, education, and research. View Source . First, you must obtain a prescription for CPAP therapy from your healthcare provider. Second, you must successfully complete a compliance period with the CPAP machine to demonstrate that you are using the treatment correctly and regularly Trusted Source American Academy of Sleep Medicine (AASM) AASM sets standards and promotes excellence in sleep medicine health care, education, and research. View Source .

In order to write you a prescription for a CPAP machine, your doctor must confirm that your sleep difficulties are caused by sleep apnea and not another condition. Your doctor will first check for symptoms of obstructive sleep apnea Trusted Source Medline Plus MedlinePlus is an online health information resource for patients and their families and friends. View Source , including:

• Loud snoring throughout the night
• Gasping or snorting during sleep
• Excessive daytime sleepiness
• Forgetfulness
• Headaches
• Drowsiness or falling asleep while driving

Sleep Study and CPAP Prescription

If your symptoms indicate you might have obstructive sleep apnea, the next step is to take a sleep study Trusted Source National Heart, Lung, and Blood Institute (NHLBI) The NHLBI is the nation's leader in the prevention and treatment of heart, lung, blood and sleep disorders. View Source . Doctors can test for sleep apnea with an overnight in-lab sleep study, also called polysomnography, or with a home sleep test (HST) you’ll self-administer before sleeping in your own bed. 

After reading and interpreting the results of your sleep study, your doctor may diagnose you with sleep apnea and work with you to develop a treatment plan.

CPAP Compliance Requirements

In order to be eligible for reimbursement Trusted Source National Library of Medicine, Biotech Information The National Center for Biotechnology Information advances science and health by providing access to biomedical and genomic information. View Source , the Centers for Medicaid and Medicare (CMS) require proof that you are using the CPAP machine at least four hours per night, on 70% of nights, in a consecutive 30-day period. Most machines record your use 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’re unable to meet these requirements during the first three months, you may have to restart the process.

While these are the most common prescription and compliance requirements for CPAP coverage, each provider has its own specific rules. Review your policy to learn about the requirements specific to your insurance provider.

What Does CPAP Insurance Coverage Include?

Insurance coverage and costs for CPAP equipment depend on your specific policy and whether you are complying with usage requirements. When considering costs and insurance coverage, it’s important to look beyond just the machine. We’ll explain typical insurance coverage for CPAP machines, supplies, and optional accessories. 

CPAP Machines

Your insurance coverage for a CPAP machine depends on your provider. Some providers reimburse you for the cost of purchasing the machine outright, while others require a rent-to-own plan under which you must use the machine for a set period before owning it.

Most CPAP machines cost between $500 and $800. BiPAP and APAP machines frequently run in the thousands of dollars. Typical insurance plans, including Medicare and Medicaid, cover up to 80% of these costs once the policy-holder has met their deductible. Some CPAP machines may not be covered at all. For example, some insurance providers consider travel CPAP machines to be non-essential devices.

If you are on a rent-to-own structure, your monthly fee typically equals the cost of the CPAP machine divided by the number of rental months. The exact amount your insurance company pays depends on your policy. If you rent for longer than a year, you may need to pay a second deductible.

If your insurance company determines you are not using the machine frequently enough as per your policy, they may stop covering their portion of the machine rental. 

Be aware that if you decide to stop CPAP treatment and decide later that you want to try the treatment again, your insurance company may require you to re-do the prescription process to  qualify for coverage. The doctor’s appointments and sleep study may pose additional costs, depending on your policy. 

If this all sounds overwhelming, CPAPinsurance.com can help simplify the process. The site walks you through your options and connects you with recommended providers so you can get your CPAP machine and supplies through insurance — without the guesswork.

CPAP Supplies

When beginning CPAP treatment, the biggest upfront cost is the CPAP machine itself. Then there are supplies that need to be replaced over time, including:

• Masks
• Mask components
• Tubing
• Filters
• Chin straps
• Headgear
• Water chamber

The costs for each component vary. Filters, which need to be replaced frequently, run between $5 and $30 each. Most masks cost at least $100, and other equipment ranges between $20 and $100 per component. Some rental plans may include the cost of replacement equipment, which is something to bear in mind when comparing the cost of buying outright versus purchasing with insurance.

Many insurance providers use the Medicare guidelines for replacing equipment: Trusted Source U.S. Department of Health and Human Services View Source

However, each provider has its own set of replacement guidelines. Among state Medicaid programs, 51% adhere to these guidelines, but 39% allow for less frequent replacement of CPAP equipment. Only 10% allow for more frequent replacement.

CPAP Accessories

As you adjust to CPAP treatment, you may want additional accessories for more comfortable sleep and easier travel. There are a number of optional accessories you can purchase for your CPAP machine. These include:

• CPAP pillows are cut to accommodate the machine and tubing and allow you to move during the night.
• CPAP cleaners may help disinfect your machine and extend its longevity.
• Mask liners can wick away moisture and ensure a tighter seal to keep the mask in place.
• Hose holders help the CPAP machine feel softer against the body and look less medical in appearance.
• CPAP batteries are convenient for travel when you don’t have access to a power outlet.
• Travel bags can hold all your CPAP equipment when you’re on the go.

Insurance does not typically cover any products that are considered optional. Costs for these products can vary depending on the quality. More expensive accessories often come with warranties of one to three years.

Does Medicare Cover CPAP?

Medicare considers CPAP devices to be durable medical equipment (DME) Trusted Source Medicare.gov Medicare.gov provides essential information about signing up for and using Medicare, which is health insurance for people 65 or older. View Source and provides 80% coverage under Part B as long as you meet certain conditions. First, your doctor must diagnose you with obstructive sleep apnea following an approved laboratory sleep study or an at-home sleep study and give you a prescription for a CPAP machine.

Then, Medicare covers a 12-week initial period of CPAP therapy for obstructive sleep apnea, as long as you meet one of the following requirements: Trusted Source Centers for Medicare and Medicaid View Source

• You have an hourly AHI between 5 and 14 and a comorbid condition Trusted Source Medicare.gov Medicare.gov provides essential information about signing up for and using Medicare, which is health insurance for people 65 or older. View Source related to obstructive sleep apnea, including hypertension, history of stroke, heart disease, excessive daytime sleepiness, insomnia, mood disorders, and impaired cognition.
• You have an hourly AHI of 15 or higher.

You must also meet Medicare’s compliance requirements, which state that you must use the machine at least four hours per night, 70% of the time or more, during the first three months. If you fail to meet these requirements, you’ll need to begin the process again. This involves completing another sleep study, either in a lab or at home, and obtaining another prescription from your doctor.

If the CPAP therapy helps improve your sleep apnea symptoms during the 12-week period, Medicare will continue to cover the cost of your CPAP equipment. Trusted Source Centers for Medicare and Medicaid View Source With Original Medicare coverage, you pay 20% of the machine rental plus the cost of supplies such as the CPAP mask and tubing. Once you meet your Medicare Plan B deductible, Medicare pays for the rental of the machine for 13 months if you use it continually. After 13 months, you own the machine.

Does Medicaid Cover CPAP?

Medicaid programs vary by state, and typically follow the same guidelines as Medicare Trusted Source Medicaid.gov View Source . You need a sleep test, diagnosis of obstructive sleep apnea, and prescription from your doctor. Your AHI must also meet one of the same requirements as for Medicare:

• AHI index between 5 and 14, along with a comorbidity related to obstructive sleep apnea
• AHI 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 the CPAP treatment. You must also adhere to the same compliance requirements as Medicare recipients, namely using the machine at least four hours every night on 70% of nights.

Can You Buy a CPAP Machine Without Insurance?

Insurance plans can significantly help with the cost of a CPAP machine. However, if you have a high deductible, you may consider bypassing insurance and purchasing CPAP equipment on your own.

When making your decision, calculate whether your CPAP equipment is likely to cost more than your deductible, remembering to budget the ongoing costs of tubes, filters, and other replacements. You might be able to find direct-to-supplier CPAP manufacturers with lower prices than those available through your insurance plan, though be sure to check if these devices are approved by the FDA.

When you choose to buy your CPAP equipment without insurance, you can skip the rent-to-own process and own your machine right away. You also avoid the insurance requirements of treatment compliance. This eliminates the risk of needing to return your machine and restart the prescription process.

Another benefit to paying a medical equipment supplier directly is the wider selection of products, since insurance often restricts you to covered suppliers. 

Keep in mind that whether or not you use insurance, you’ll still need to complete a sleep study — either in a lab or at home — and obtain a CPAP prescription. 

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