How do I know if my insurance covers my positive airway pressure (PAP) equipment?
Most private health insurance policies cover PAP equipment: however, the level of coverage and rules for coverage will depend on your specific insurance policy. Review your insurance policy to determine if, and to what extent, your PAP equipment is covered.
Medicare generally covers a 3-month trail for PAP therapy, over which your compliance and reaction to the treatment are measured. If you meet Medicare’s criteria, you will then qualify to continue using your machine.
What are my purchase options?
Your insurance provider may require you to either buy or rent your PAP machine. Usually, if paying through insurance, what you pay out-of-pocket should be the same, regardless of whether you rent or buy.
Buy the machine through insurance
You may be required to purchase your machine by your insurer. This would require that you pay for the machine up front with the cost depending on your insurance deductible and out-of -pocket limits.
Rent the machine through insurance
Your insurer may require that you rent your machine instead of purchasing it outright. You would pay monthly installments on the machine for a set period, usually between three to ten months, after which the machine would then be yours. This spreads your payment for the machine out over a longer timeframe so that you are not paying a lump sum up front. This also allows the insurance company to measure your compliance during the first few months of your treatment to determine if you are using your machine. If you are not compliant over that period, your insurer may not continue to pay for the treatment and may require that your return your machine or arrange to self-pay going forward.
Self-pay is an option that may be cheaper than going through insurance for both the machine and supplies. If you have a high-deductible insurance plan and will be paying a large cost outright for your machine, you may choose to pay for the machine yourself without using your insurance. Many durable medical equipment (DME) and online providers have lower prices for cash purchases vs. insurance. Using this payment method, you also would not be subject to compliance criteria set by your insurer. Prior to purchasing your machine, you would research to determine if you may purchase your machine at a lower cost through different supply companies.
What is “compliance”?
Compliance or adherence are terms used to describe how often you use your machine. The Centers for Medicare and Medicaid Services (CMS) requires an individual to use their machine at least 4 hours per night at 70% of nights during a consecutive 30-day period (during the first three months of usage); this means that in a 30-day period, you must have used your machine for at least 4 hours on at least 21 days during that period. Many private insurers mimic CMS guidelines: however, you should check directly with your insurer to determine your specific compliance requirements.
Once you begin using your machine, your usage data is collected and is either remotely transmitted to the DME company or physician/office where you obtained your machine or is downloadable from a memory card in the machine. This information is shared with your insurance provider for the insurer to determine whether you are compliant with their usage requirements.
If you are not compliant with your insurer’s requirements (i.e., you are not using your machine enough), your insurer may stop paying for your machine, supplies and/or other sleep care services; if you are currently renting (and do not own your machine), your insurer may require that you return the machine. You may then have to pay for a machine and/or supplies out-of-pocket to continue your treatment.
What else should I be aware of?
You will also need to purchase supplies for your machine (mask, hose, etc.). Supplies may be at least partially covered by insurance if you remain compliant; however, they may also be cheaper if purchased without insurance.
Just like with any other product or service you purchase, you should price shop different DME providers, both in-store and online, and with or without insurance to ding the best prices for your machine as well as supplies. Depending on your co-pay, deductible and out-of-pocket limits of your insurance policy, it may be cheaper to purchase your machine and/or supplies outright instead of going through your insurance. Different equipment providers may also charge different prices for the same equipment or supplies.
Talking with Your Healthcare Provider
When prescribed your treatment, talk with your physician regarding all treatment options to see if there are lower-cost treatment options or if there are any assistance programs available.
Also, if you have any issues with your treatment, it is treatment to talk to your healthcare provider right away. For example, if you cannot tolerate using the machine at night or your mask does not fit properly, you should talk with your physician’s office to troubleshoot these issues so that you can ensure you are effectively treated and able to use your machine long-term.
Disclaimer: The information provided in this resource applies to the United States only and may not reflect practices in other locations.