Originally posted on https://wellawaresystems.com/does-insurance-cover-cpap/

 

CPAP (Continuous Positive Airway Pressure) machines are a vital treatment method when it comes to mitigating the effects of sleep apnea. It works by continuously sending air through your throat so that your airway stays open and unobstructed while you sleep. This process counteracts the pauses in breath that occur during sleep in patients with sleep apnea.

CPAP machines are one of the most common ways to treat sleep apnea. While this therapy may be uncomfortable for you to get used to at first, it can help you to lead a much healthier and restful life. If you have been diagnosed with this illness, or suspect you may be suffering from it, then you may be wondering how you can get this effective treatment method.

Is a CPAP covered by insurance?

If so, what’s the CPAP machine cost with insurance?

Keep reading to learn all the rules surrounding CPAP machines, prescriptions, insurance, and more.

Do I Need a Prescription to Obtain a CPAP Machine?

The answer to this question is a little complicated. The short answer? Not exactly. The FDA requires patients to obtain a prescription to purchase a full CPAP machine. However, the FDA does not require a prescription to buy CPAP supplies.

Some suppliers have circumvented this discrepancy by offering parts of a CPAP machine separately. This process allows them to provide CPAP equipment to consumers who do not have a prescription. A few of these suppliers have completely reorganized their business models so that they do not even offer any CPAP equipment that requires a prescription anymore. The equipment these companies sell to those without a prescription does not differ in quality from supplies that do call for a prescription.

Assembly for masks purchased in this manner is usually quite simple. If you follow the instructions, you should have no trouble, but you could always contact the customer service team.

Is Ordering a CPAP Machine Without a Prescription Legal?

Technically, ordering a full CPAP machine without a prescription is not legal. However, if were to purchase necessary components, packaged separately, then it is considered CPAP accessories, and it is permissible to buy. For example, you could easily buy a CPAP mask from a retailer online, but you would not be able to buy the full machine.

The FDA only requires a prescription because it designates CPAPs as Class II medical devices that pose some risk to the user. Even though there is risk involved, as there is with most things in life, that does not mean that these machines are inherently dangerous.

What Are the Benefits of Buying CPAP Equipment Without a Prescription?

Getting your CPAP supplies without a prescription can save you both time and money. Not having to get a prescription means one less trip to the doctor’s office. Also, without a prescription, you have more options when buying and can select a less expensive choice.

FAQ’s

Keep reading to learn all about CPAPs and insurance so that you can make the best decision for your situation.

Does Insurance Cover a CPAP?

Unfortunately, insurance is a whole different beast compared to prescriptions. There are many different policies and rules that you need to understand before you can get a CPAP machine through your insurance. The stringent requirements have driven many patients to just pay for the devices out of pocket.

Insurance companies partially cover CPAP machines. Coverage for CPAPs can differ greatly compared to other medically necessary treatments. Many insurance companies will require patients to enter into a rental agreement that the company only partially subsidizes.

For those who are on very tight budgets, going through insurance can help the monthly payments to be lower. However, the largest problem is that, even with insurance, most people will rent and pay more for the device than they would have if they had just purchased it outright.

How Much is a CPAP Machine with Insurance?

The amount you will have to pay to use a CPAP device through your insurance varies by policy, but generally takes the form of copays and deductibles. There are very few, if any, insurance policies that will fully cover the cost of a CPAP device.

You must also be aware that many insurance companies require proof of usage, or they will terminate your rental agreement. Some companies make users give them access to data collected by the machine nightly to determine if it you are using it as agreed. If your usage does not match up to the insurance company’s expectations, then they may take back the machine.

Additionally, sharing this data makes many patients uncomfortable because they deem it as an invasion of privacy. If you want your machine to be yours and to keep your privacy intact, then you may have to purchase your CPAP yourself.

How Much is a CPAP Machine without Insurance?

The full cost of CPAP machines can range from $500 to $3000. The average price tends to hover right at about $850. However, some suppliers may provide payment plans to make the cost less burdensome outright.

Even though these prices may look steep, they are often lower than insurance-mandated prices. Without insurance regulations, consumers have more options, and suppliers must be competitive to ensure sales. Additionally, rental rates can add up over time to exceed these prices, even if the monthly rate is more doable.

Does Insurance Pay for a Second CPAP Machine?

Most insurance companies will not cover a second CPAP machine because they follow strict replacement schedules. They will only supply replacement parts after a certain amount of time or if you demonstrate a certain amount of need. However, many people consider buying a second machine for travel, emergency, and sanitary reasons.

Many patients have found that having a second machine strictly for travel, or in the case of a malfunction, helps them to use the device more regularly. Regular usage keeps their condition in check more thoroughly. If you are interested in owning a second CPAP device, you will almost certainly need to pay for it out of pocket.

Does Medicaid Cover CPAP?

Medicaid will cover CPAP, but the amount of coverage varies by state, and it requires authorization. Deductibles and copays will almost definitely apply unless you also have secondary insurance. It is also important to note that CPAP supplies are covered differently than the machine itself and may have different standard rates.

Does Medicare Cover CPAP Machines?

Medicare does cover CPAP machines, but patients will still be required to pay 20% of the device’s cost. Patients will also be required to rent and use the machine regularly for 13 months before ownership. Medicare also requires that you purchase from a supplier that enrolls Medicare.

When using Medicare, you may have to pay the entirety of the bill up front, and be reimbursed by Medicare later. For many people with low incomes, this may be challenging, and they may need to consider other options.

Bottom Line

The world of prescriptions and insurance, regarding CPAP machines, can be quite confusing. Unfortunately, it is difficult to provide consistent information because there are so many variables. If you would like more specific information, then you should speak to your health care provider as well as a representative from your insurance company.

Your doctor should be able to tell more of the pros and cons of using a prescription for you specifically. They will also be able to guide you in terms of which machine may work best for you. Doctors can also assist with choosing the type of mask that will be most comfortable.

Similarly, your insurance company rep will likely be able to inform you more accurately regarding how much you will be expected to pay if you choose to use their services. If you have multiple insurances, you may need to speak to representatives from each company to be sure you have the most comprehensive information. Gathering intel from each company is vital because each policy may cover different aspects of your total cost.

Even though sleep apnea is a scary condition, it can be easily treated with the right CPAP machine and consistent usage patterns. Consider going through a cost-benefit analysis so that you can make the best decision for yourself long-term. Make sure to thoroughly evaluate your options when it comes to obtaining a CPAP machine so that you get the best selection at the lowest price.