Are CPAP Machines Covered by Insurance?

By Susan – Certified Sleep Science Coach

While CPAP therapy is considered the “gold standard” treatment for OSA, it can get expensive. The prices of CPAP machines range between $500 and upward of $1,000. What’s more, you need to consider the costs of regularly replacing CPAP supplies and scheduling visits to your doctor.

This is where your insurance comes in handy. But with so many requirements you need to meet and terms to understand, starting therapy through insurance can be overwhelming. 

In this guide, we’ll break down the complexities of CPAP insurance from private health insurance, Medicare, and Medicaid coverage to purchasing CPAP without insurance. That way, you’ll be empowered with the financial know-how to start and stick with your treatment.

An indispensable part of sleep apnea treatment, CPAP machines are covered by many insurance policies. The cost of replacing the machine every 5 years is also covered.

To qualify for one, you’ll need a prescription for CPAP therapy from your doctor. You’ll also need to meet your provider’s compliance requirements for CPAP insurance coverage (more on that later).

CPAP, BiPAP, and auto CPAP

CPAP machines fall under the DME category, which most insurance plans cover. They’re also the most common treatment for sleep apnea, so chances are, your provider will deem these devices “medically necessary.” This typically applies to a regular CPAP, auto CPAP, or BiPAP machine–depending on your insurance policy and diagnosis.

CPAP Rental

In some cases, you might not be reimbursed for purchasing a machine outright. Instead, your insurance provider may require you to rent a CPAP and use it for a certain number of months.

If your policy follows this kind of rent-to-own structure, your provider will cover a portion of the monthly fees. Once you’ve completed your plan’s rental term, you’ll own the device. 

Now, what if you’re planning to rent a CPAP machine temporarily for travel or because your main device broke down? You’ll still have to verify the coverage details with your provider.

Travel CPAP

If you already own a CPAP machine, your insurance might not consider a travel CPAP essential. This can be on a case-by-case basis, though. It all depends on your lifestyle and insurance carrier.

If you travel frequently, talk with your healthcare provider and insurance representative to see whether a travel CPAP is eligible for coverage. 

You can’t use a CPAP machine without the necessary supplies. That’s why your insurance can extend its coverage for various CPAP accessories. When covering the regular replacement of supplies, insurance providers usually follow an industry-standard CPAP resupply schedule. 

Below are the CPAP supplies covered by most insurance plans, as well as the frequency of replacing them:

CPAP Supplies	Frequency of Replacement
Mask cushion	Every 2 weeks or every month
Mask headgear/entire CPAP mask	Every 6 months
Filters	Every month (disposable) and every 6 months (non-disposable)
Tubing	Every 3 months
Water chamber	Every 6 months

Not all CPAP supplies are covered by insurance providers. These include optional accessories, such as:

• Hose lifts or clips
• Tube brushes, mask wipes, and other CPAP cleaning supplies
• Mask liners
• Travel bags
• CPAP bed pillows
• CPAP batteries or power stations

Your doctor will play a key role in preparing the documentation you need for CPAP insurance coverage. For a smooth approval process, you should clarify the specific requirements with your carrier. 

In general, these are the insurance requirements for CPAP therapy:

Prior Authorization

Some health plans may require prior authorization or preauthorization before covering (or continuing to cover) your CPAP treatment. This involves a set of criteria, such as the medical necessity, cost-effectiveness, and benefits of the treatment.

Sleep Study and Diagnosis

Simply explaining your sleep apnea symptoms to your doctor isn’t enough to meet CPAP insurance coverage. For an accurate diagnosis, you’ll need to undergo a sleep study. Depending on your insurance provider, you might have to take an in-lab sleep study instead of a more convenient home sleep test. 

Prescription

Once you’re officially diagnosed with sleep apnea, your doctor will provide you with a prescription for CPAP therapy, which will serve as official proof that a CPAP machine is medically necessary. Having a prescription is a must whether you’re buying a machine out-of-pocket or through your insurance. 

Compliance

One of the most important insurance requirements for CPAP is adherence or compliance. To be considered “compliant,” you’ll have to use the machine at least 4 hours every night for 70% of the first 90 days, among other criteria your insurance provider may set. 

CPAP compliance not only serves as a requirement for continuing insurance coverage —it’s also a great way to see whether CPAP therapy is working for you. 

Here are a couple of things you’ll need for compliance and therapy reporting:

• Sleep data: Modern CPAP machines are built to record your nightly therapy data. This includes your apnea-hypopnea index (AHI), hours of use, and leak rate. You and your doctor can download your compliance report using the device’s SD card, app, Bluetooth, or WiFi. Or if you’re often on the go and unable to download your compliance report, RespShop can help you out through our Remote CPAP Data Downloading Service. Simply send us your machine info so we can remotely access your device. Then, we’ll generate and submit your compliance report to your insurance or healthcare provider. 

• Regular visits: Your insurance company might need you to make follow-up appointments with your physician or sleep doctor. During these visits, your doctor will review your sleep data and check whether you’re benefiting from CPAP therapy. 

Before purchasing any CPAP equipment through insurance, be sure to contact your provider and ask these questions:

Purchasing

• Can insurance pay for a machine that I’ve already purchased?
• Will I be paying out-of-pocket for equipment purchased from out-of-network DME providers?
• Will I get a new machine? Not necessarily – again, be sure to ask.

Requirements

• Is preauthorization required?
• Do you accept a paper claim or an electronic claim? 
• What documentation will I need to send with my claim? 
• Will I need to add any modifiers to my claim? 

Costs

• What percentage of the cost of the CPAP equipment is reimbursable? / What percentage of the cost will insurance cover?
• What deductible, coinsurance, or co-pay* amount must be met before I am eligible for any reimbursement?

*We’ve talked about how insurance providers will only provide partial coverage for the purchase of a CPAP machine. This is because, on top of your monthly premiums, you’ll likely need to pay these out-of-pocket costs:

Deductible: The fixed amount you pay yearly before your insurance kicks in. For instance, if you’ve already met your deductible by paying out-of-pocket for previous healthcare expenses, your insurance will start helping you out with the cost of your CPAP therapy. 

Co-pays: The fixed amount you pay after meeting the deductible. For example, a CPAP machine costs $2,000 and your co-pay is $400. You still need to pay the $400 even after meeting your annual deductible. The insurance will cover the remaining $1,600. 

Coinsurance: Another way you and your insurance can share the bill is coinsurance. The difference between coinsurance and co-pay is that the former refers to the percentage of the total cost rather than a fixed amount. Using the same example above, if your coinsurance is 20%, you’ll have to pay $400 (20% of the $2,000) after meeting the deductible. Your insurance covers the remaining 80% (or $1,600).

In most cases, insurance can significantly alleviate the costs of purchasing equipment. But because of the tedious process of submitting claims, some people prefer buying CPAP without insurance.

If you want to get your equipment directly from sellers like RespShop, all you need is a valid CPAP prescription from a doctor. 

So should you buy CPAP without insurance and take charge of your sleep health independently? Let’s look at the factors you need to consider:

Prices of In-Network vs Out-of-Network Suppliers

Third-party CPAP sellers might offer lower prices than in-network suppliers. RespShop, for example, is not a participating provider with any insurance carriers. That’s why we can provide CPAP machines and supplies at the lowest prices possible.  

Deductible

Before getting CPAP insurance coverage, you’ll need to meet your deductible, not to mention your co-pay or coinsurance. So if you have a high deductible and haven’t met it yet, it might be more cost-effective to self-fund your CPAP therapy. 

Frequency of Replacement

Insurance companies follow a strict CPAP replacement schedule. If you need to replace your machine or supplies more frequently, you’ll still need to pay out-of-pocket for them.

Requirements

With insurance companies, you’ll have to fulfill an extensive list of requirements to get and continue coverage. If you don’t meet your policy’s compliance requirements, your provider might take the machine back. 

When you buy a machine from a direct CPAP retailer, there’s no need to go through a trial period or worry about compliance — your device and supplies are yours from day one. 

Selection

Your insurance plan’s contracted supplier might not have the CPAP machine you’re eyeing. Some suppliers don’t even let you choose! When you decide to purchase one out-of-pocket, you have the freedom to choose any device you like.

If you’re leaning towards buying a CPAP machine without insurance and on a budget, you can find used or refurbished CPAP equipment from authorized resellers at huge discounts. You might even be qualified to get a free CPAP machine from registered non-profit organizations. 

Effort

Another reason people prefer to get CPAP without insurance is the stress-free process.

Does submitting a claim with your carrier often involve numerous phone calls? Will you have to wait for months before starting your therapy? Think about how the process usually goes with your provider, calculate the costs, and decide if it’s worth the headache. 

An authorized seller of CPAP equipment, RespShop does not directly bill insurance companies. But we provide all the information you need for submitting a claim yourself on our website.

Don’t have a CPAP prescription or never done a sleep study? We’re here to help. RespShop is partnered with board certified sleep physicians who offer home sleep testing, interpretation and CPAP prescription services.

All of our Prescription Assistance Services are done online for your convenience. Simply select the service you need and book an appointment time. You’ll receive an email with a link to your online appointment. If you choose to do a home sleep apnea test, you’ll get the testing device in the mail. It’s that easy!

After your appointment, you’ll receive your CPAP prescription by email. Once you have your prescription, you can go ahead and buy a CPAP machine from any supplier. If you’re not sure what machine is right for you, the RespShop team is here to help you decide which CPAP device and supplies you need.

Best of all, with our price protection guarantee, we make sure that you’re getting the best bang for your buck.

Browse our collection of CPAP machines and supplies today! If you need help with filing a claim or getting a prescription, contact our team using one of the options below.