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Insurance Codes
Does My Health Insurance Cover CPAP Therapy?
Virtually all health insurance plans now cover CPAP therapy for obstructive sleep apnea, but the benefits and conditions of coverage vary from plan to plan. Most of the costs incurred by CPAP therapy fall into two categories: clinical care and equipment.
Clinical care includes doctor visits and consultations, as well as procedures like in-lab sleep studies. All of these patient/doctor interactions are subject to insurance plan rules on copayments, deductibles and coinsurance, as well as in-network/out-of-network provider rates. Another factor to consider is that sleep medicine providers are considered specialists, so some insurance plans will require a referral from your primary care doctor prior to treatment. Most sleep centers/sleep medicine providers will be familiar with the insurance benefits and authorization requirements for popular health plans within their region, but patients should contact their insurance plan directly with questions or to verify coverage.
Equipment costs for CPAP therapy can be substantial, with some CPAP machines running as high as $3000 or more (though we offer considerable discounts for its inventory, as dramatic as 70% off on various PAP devices). There are also ongoing supply costs to reckon with, as patients need to periodically replace equipment like CPAP masks and seals, tubing, filters and other replaceable parts. Thankfully, most insurance companies cover these equipment-related costs, however, the details and authorization process changes from plan to plan.
CPAP Machine Rental or Purchase?
Insurance plans may require a CPAP machine be rented from an approved vendor for a set amount of time before purchasing. During this probationary rental period, patients must meet compliance thresholds by demonstrating active use of their CPAP device. The rationale behind these compliance requirements is that patients who can’t commit to the regular use of their CPAP will not be covered. For some insurance plans, the monthly rental fee effectively serves as an installment payment, with the patient owning the machine after a certain number months of active use (Medicare patients, for example, own their devices after 13 months). One of the downsides of this insurance practice is that, during the rental period, the patient deductibles commonly reset. This adds to the direct cost to the patient in an unpredictable manner.
Many private insurers allow patients to purchase a CPAP machine immediately once therapy is prescribed, or offer reimbursement for purchases from online dealers. Private insurance plans also often reimburse patient claims for the out-of-pocket costs for replacement parts, like CPAP masks, hoses, filters and other related expenses. (Wondering how often to replace CPAP supplies? Check out our suggested CPAP equipment replacement schedules) Again, the coverage details, authorization process and rules for reimbursement changes from plan to plan, so contact your insurance company to verify.
Does Medicare & Medicaid Cover CPAP Therapy?
While Medicare covers CPAP therapy for sleep apnea, healthcare providers must follow stringent treatment guidelines. These Medicare protocols include a requirement that the PAP machine and related supplies be procured from an approved Durable Medical Equipment (DME) provider. We are not a Medicare-approved DME provider, and purchases made on SleepDirect.com cannot be submitted as a Medicare beneficiary to Medicare CMS or a Medicare division of an independent insurance company.
Medicaid programs are administered by state governments, with each state setting its own guidelines regarding eligibility and services. While Medicaid programs generally follow Medicare coverage guidelines for CPAP therapy, including requirements to go through approved DME provider, the specific rules differ between states and various Medicaid programs. Contact your Medicaid insurance provider for specific coverage benefits and authorization rules.
Can I Bill Insurance for Reimbursement of CPAP Equipment Costs?
It is important to understand that we do not charge or bill any insurance, including Medicare and Medicaid. As our name implies, we sell direct to you, the patient and customer. Private insurance plans may reimburse patients for the out-of-pocket costs of their CPAP equipment
The first step to filing an insurance claim for reimbursement is contacting your insurance provider to see if it is allowed. While many insurers do offer this option, others, like Medicare or Medicaid, forbid claims for reimbursement from patients, or even acquiring PAP equipment outside of approved channels. Provided your insurance plan does offer reimbursement for out-of-pocket costs, make sure you ask what specific information they require. This includes what type of claim form they prefer. Patients may be able to use a generic claim form, but some insurance providers have a particular form they need filled out.
The claim process will usually require adding medical billing codes for the specific equipment. These billing codes, called HCPCS (Healthcare Common Procedure Coding System) codes, are uniform and standard practice during the claims process. Patients should plan on submitting their purchase invoice with the claim form, as proof of purchase. It’s important that your invoice and billing codes match up. One common issue is that a CPAP mask and headgear have separate billing codes, though they are often sold together. We provide the following list of the most common HCPCS codes for your convenience.
Can I use my Health Savings Account (HSA) or Flex Savings Account (FSA) for CPAP Equipment?
We accept FSA and HSA dollars for all prescription and even some non-prescription CPAP supplies (including machines, masks, batteries, and cleaners!), as long as your FSA or HSA card is affiliated with a major credit card.
Using a Health Savings Account (HSA) or Flex Savings Account (FSA) can be an effective strategy for reducing health costs, particularly known fixed costs like CPAP. Patients utilizing an HSA/FSA can deposit (or have the employer deposit) funds into the account tax-free for medical expenses. Most CPAP equipment is eligible for HSA/FSA coverage, while we are able to use these funds for purchases from our site. Please make sure you use those funds before your plan year-end so as to not lose them.
Flexible spending accounts (FSA) and health savings accounts (HSA) are programs that allow you to set aside money (before taxes) for specific health care expenses. If you’re unsure whether or not you have an FSA or HSA, please check with your employer or insurance company.
Can I Afford CPAP Therapy Without Insurance?
One of our stated missions is to provide our customers with the best CPAP products available at the most cost-effective prices, not limited by insurance barriers. Our CPAP products are offered at rates that are often significantly discounted from standard MSRP, so much so that they can be a viable option for uninsured patients. We also serve as an attractive alternative for those patients with high-deductible plans. If your CPAP therapy is truly an out of pocket expense, why pay extra to go through more expensive and less convenient channels? We hope to offer you affordable options worth considering.
What are the insurance codes I need to submit for my CPAP equipment?
Most private insurance companies will reimburse for durable medical equipment at some level. The CPAP Shop will provide you with a detailed purchase order which can be submitted to your insurance company for reimbursement. We are considered an out-of-network provider for many plans. Your individual insurance company will need to determine your reimbursement rates.
Below are the codes used for submission on insurance claim forms.
- E0601 NU: CPAP Device Purchase
- E0470 NU: BiPAP without back-up rate feature
- E0471 NU: BiPAP with back-up rate feature
- A7030: Full face mask
- A7031: Full face mask cushion
- A7034: Nasal mask (mask or cannula type) used with CPAP device with or without head strap
- A7033: Nasal pillows/seals, replacement parts for nasal interface, pair
- A7035: Headgear used with CPAP device
- A7036: Chin strap used with CPAP device
- A7037: Tubing used with CPAP device
- A7038: Disposable filter used with CPAP device (ultra fine)
- A7039: Non-disposable filter used with CPAP device (foam)
- A7044: Oral interface used with CPAP device
- E0561: Passover humidifier
- E0562: Heated humidifier
- E7046: Heated humidification chamber
- E1399: Miscellaneous durable medical equipment items
- A9900: Miscellaneous components of accessory items