Insurance Coverage for Sleep Studies, Sleep Apnea and CPAP

Insurance

Diagnosing and treating a sleep disorder is pivotal to your health and well-being. That being said, the process of getting the necessary treatments and diagnosis can make patients apprehensive if they do not know the costs that are ahead. Health insurance can be complicated, especially when it comes to understanding a new-to-you treatment like CPAP therapy. Today, we will talk about what you can do to save money, how to get good treatment and how to work with your insurance to cover the costs.

Getting Diagnosed: First Steps

Many are surprised to learn that they cannot buy a CPAP machine without first getting a prescription for one from a doctor. These machines aren’t the type of medical device that people can really abuse, in fact, it can be a challenge for some users to stay compliant. Nevertheless, a visit to the doctor is the first step in getting your diagnosis.

You are going to need to make an appointment with your doctor to discuss the symptoms you are experiencing that lead you to believe you may have sleep apnea. Some common symptoms of a sleep disorder are:

  • Fatigue
  • Depression
  • Snoring
  • Irritability
  • High Blood Pressure1
  • Sexual Dysfunction
  • Lack of Concentration

If your doctor believes you are presenting symptoms of a sleep disorder, they will refer you to have testing done to confirm and diagnose the root cause. It will likely be an option of two different tests, depending on your needs. It would likely either be an at-home sleep test or an overnight study in a sleep center. If you want specifics on the differences between the two, click here. These are the different types of sleep tests performed:

  1.     In-Center PSG (Polysomnography) – The general sleep study/baseline
  2.     Split Night PSG (50/50 or Split)
  3.     Titration Study
  4.     HSAT or HST (Home Sleep Apnea Test)
  5.     MSLT (Multiple Sleep Latency Test)

Dr. Mostafavi says this of Advanced Sleep Medicine’s Sleep Center, “We make our in-center sleep studies cozy to ensure you have a normal sleep to get accurate testing.” Once your results are in, your doctor will meet with you to discuss the course of treatment best suited to your needs. If it is deemed medically necessary, you should be authorized to have some coverage for a CPAP machine.

How Your Doctor Can Help Keep Costs Low

Unfortunately, out of pocket expenses are on the rise, but there are certain steps your doctor can take to help keep costs low. However, it’s important to remember that in the long run, it can cost less to make the investment in your health now than be faced with the expensive outcome of untreated sleep apnea.

Your doctor will suggest whatever treatment option they think is best for you regardless of cost, as this is the proper standard of care. However, they can and should also provide alternatives to you that will help to fit your budget. For example, an at-home sleep test is going to be less expensive than staying the night at a sleep center. If you are a good candidate for an at-home test, this will be an option to try.

If after a study, they have ruled out the possibility for obstructive sleep apnea (OSA), they may recommend an oral appliance to help with snoring. This is a less expensive treatment option than surgery to aid the upper airway. If you are showing mild symptoms of a sleep disorder, they may even suggest simple lifestyle changes like adopting a healthy diet or quitting smoking. Both of these are low cost and free.

If you do have OSA and require a sleep machine, your doctor will be able to recommend lower cost items and will stress the importance of compliance in order for insurance to keep paying their contribution.

How to Work With Your Insurance Provider

Each person’s insurance plan can vary, so it’s important to know how to work with your provider.

HMO

An HMO stands for Health Maintenance Organization. They have their own network of providers in which they provide coverage. If you choose a provider outside of this network, you will pay a substantial amount more. Before you seek treatment, call your provider to see that you are going to a facility that will be covered. HMO insurance plans require authorization. Once your insurance has been properly authorized, you can have a sleep study. Deductibles and co-payments may still apply.

Medi-Cal HMO

This is health insurance coverage for those with low income. In order to be prepared, call your provider to see what criteria need to be met in order to qualify for a sleeping aid like a CPAP machine. Likely, this will first be a physical exam followed by an at-home sleep test if possible.  

PPO

PPO stands for preferred provider organization. They are typically the most popular plans, due to their ease of use and coverage. Even still, these providers require authorization before beginning a sleep study. These plans usually allow for a new mask every 30 days if you are compliant with treatment. Your out of pocket expense will vary depending on which plan you have, but most PPOs offer some form of coverage or another for the machine and supplies.  Deductibles and co-payments may still apply.

Medicare

Medicare is a federal health insurance program for those 65 and older. Medicare will also require authorizations for both sleep studies and a CPAP machine. If you have been diagnosed with sleep apnea, Medicare will allow a three month trial period of CPAP therapy. This trial will be extended if you are able to say the therapy has helped you and that you have been compliant. These factors can be dependent on the cost.

Often, many insurance companies will rent out the equipment on a monthly basis. These are the basic terms followed:

  • 3-month rental, 4th-month purchase (many PPO insurances)
  • 10-month rental (most HMO insurance and some PPO insurances)
  • 13-month rental (Medicare and other government insurance)

Call your provider to see what options are available to you and what your potential financial responsibility may be. Furthermore, it’s important that when and if you get coverage, you are compliant with your CPAP treatment. This means utilizing therapy for four hours each night. If your insurer does not see improvement in your symptoms or that you are not utilizing the device as prescribed, it is likely not going to be covered any longer. These are some reasons it can be taken away and why it is so important to remain compliant with your health and treatment.

The Importance of Treatment

It’s understandable to have concerns about paying for a diagnosis and treatment. Unfortunately, taking care of yourself isn’t always synonymous with low cost. However, to not take care of treating your sleep apnea results in costs that are too high to pay, financially, emotionally and physically. Some consequences of untreated OSA are an early onset of dementia, heart attacks2, strokes and diabetes3 . These extreme cardiac events and diseases can cost more long term than it would cost to treat sleep apnea, potentially preventing or eliminating the issues altogether.

As we all know, insurance cannot go overlooked when it comes to a health concern. Contact us for more information on your coverage for sleep studies today!

  1. Phillips, B. (2008). Prevalence of Symptoms and Risk of Sleep Apnea in the US Population: Results From the National Sleep Foundation Sleep in America 2005 Poll. Yearbook of Medicine,2008, 319-321. doi:10.1016/s0084-3873(08)79227-7
  2. Journal of the American College of Cardiology, August 2008, “Sleep Apnea and Cardiovascular Disease”. http://www.onlinejacc.org/content/52/8/686
  3. “The Link Between Sleep Apnea and Diabetes.”https://www.sleepdr.com/the‐sleep‐blog/the‐link‐between‐sleep‐apnea‐and‐diabetes/

Comments

  1. Marian Budzynski-Moldan Reply

    What is the difference between the cost to insurance when the Place of Service is an inhome sleep study vs. oncampus outpatient hospital sleep study?

  2. Mischa Brooks Reply

    Very informative blog post. Keep it up!

  3. SANDY MOSER Reply

    Hello, I am just wonder what I would need to do to get a new cpap machine when mind goes bad and have the insurance paid for it, I have not be to my lung dr. for about 4 years, I have just been replace the mask and hose on my own without using insurance, I do go to a primary care Dr.
    I will be going on medicare in aug. of 2022.
    My machine is still working fine, at this time, would I have to do another sleep test to get insurance to pay? Would I have to go to a ent or lung dr. to get insurance to pay? Or will my primary Dr be able to help with this? Thank

  4. Charles M Honeycutt Reply

    Where can I get reasonably priced supplies like a mask, headgear, and heated tubing and Medicare or Cigna will pay for them. Rotech is gouging on prices charging $255.00 for full face size 20L face mask. Insurance paid them $128.66 and they expect me to pay $102.93. Tubing and headgear is also overpriced and I am expected to pay the difference.

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    Many are surprised to learn that they cannot buy a CPAP machine without first getting a prescription for one from a doctor.

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