Yes, CPAP machines and supplies are considered durable medical equipment in the United States. And this means that they may be covered by your health insurance. However, this coverage will vary by state, as well as provider. Durable medical equipment, or DME, tends to include equipment and supplies authorized by your doctor for at-home treatment of medical conditions.
Note that some may be for a short-term injury or illness, such as crutches for a broken leg. Other DME can be used to treat long-term chronic conditions, such as CPAP machines for sleep apnea. CPAP stands for Continuous Positive Airway Pressure. The CPAP Machine is known to increase the air pressure in your throat to prevent your airway from collapsing while you inhale; it also helps you to snore less.
Have it in mind that the purpose of this machine is to help people with Sleep Apnea breathe easily and regularly every night while they sleep. The CPAP Machine comes with a Humidifier and you will need to get supplies like a Filter, Tube, Mask, etc, in order for it to work properly.
Indeed there are enormous benefits to using a CPAP Machine. It is the most effective treatment for Sleep Apnea that doesn’t involve surgery. It helps to reduce daytime sleepiness, heart problems and lowers blood pressure during both the day and night.
Aside a CPAP, durable medical equipment includes oxygen concentrators, nebulizers, and other respiratory supplies. These are just some of the items on a long list of equipment that meets the criteria of DME. Note that private health insurance companies are not required to cover DME, so it is crucial to check coverage with your provider.
Although some may cover DME, your particular plan may only cover certain items or provide only partial coverage. Nonetheless, prior to receiving your equipment, the insurance company will need you to provide a valid prescription from a licensed physician. Online retailers who don’t work with insurance companies still need a prescription to purchase equipment.
Other Examples of Durable Medical Equipment and How They Are Treated By Insurance Companies
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Wheelchairs are indeed the most common type of mobility device that is covered by medical insurance. Note that once your doctor has determined that you need a wheelchair, you would be able to get at least a portion of the cost covered by your insurance.
In addition, if you’re looking to upgrade to a power scooter, electric wheelchair, or another type of mobility device, getting the cost covered could be more challenging. Most times, these can only be covered if the device is going to be used in place of a wheelchair, and your doctor has confirmed it medically necessary for you to have a powered mobility aid, based on your condition.
This also entails that your medical condition must be severe enough that a standard wheelchair is not substantial to help you maintain a good quality of life. If your doctor states this in writing, your odds of having a powered mobility device covered by insurance improves, but it is still not guaranteed.
Once you have been diagnosed with diabetes, the equipment needed to monitor your condition—namely, blood glucose monitors and testing strips—would be considered DME. In most scenarios, this equipment would be covered by Medicare or your personal health insurance.
It doesn’t matter if you have Type 1 or Type 2 diabetes, and you aren’t expected to use insulin either; if you’ve been diagnosed and require testing your blood glucose levels on a regular basis, you should be able to request coverage from your insurance.
Note that these chairs are a tricky type of DME especially when it comes to having the costs covered by insurance. This is due to the lifting mechanism is sometimes considered to be a medically necessary piece of equipment, but the chair itself often is not.
Medicare, for instance, only provides coverage for the seat-lift mechanism, and not for the lift chair. Therefore, while you might be able to get partial coverage on this type of purchase, it is unlikely you’ll be able to have a lift chair fully covered.
Treatment and Therapy Equipment
Have it in mind there are many types of medical conditions that may require at-home treatment or therapy. A few common examples include sleep apnea and asthma. These conditions require regular use of a CPAP machine and a nebulizer, respectively. Note that if there is a piece of equipment you are medically required to use to treat an existing medical condition, it should qualify as a DME, and therefore, be eligible for coverage by most insurance.
If you decide instead to rent your necessary DME and not purchasing them outrightly, this should not impact your eligibility. Most insurance will offer almost the same level of coverage for the equipment, irrespective of whether it is purchased or rented. Private insurance companies like Medical Xpress and Arlington Medical Supply offer rental options on many types of medical equipment, so be sure to ask about this option if you’re interested.
Indeed a CPAP Machine is considered to be Durable Medical Equipment and most insurance policies cover them. However, you will have to call your insurance to find out exactly how you would be covered. Supplies for the CPAP Machine are covered separately and the amount of coverage varies by each state; you will need to ask your insurance about that as well.
Frequently Asked Questions
- What Is Proper Maintenance For Your Durable Medical Equipment And Supplies?
In addition to keeping your durable medical equipment operating smoothly and efficiently, a good maintenance program will help your equipment hold its value longer. Even with proper maintenance and repair, you can’t always control equipment failures, but your best bet to keep these pricy machines in good working order is consistent care. Here are a few maintenance and care tips to get you started.
- Proper usage
- Check your warranty guidelines
- Keep detailed records
- Adhere to manufacturer’s recommended equipment maintenance schedules
- Inspect the equipment on a regular basis
- Involve the operators or drivers in the equipment maintenance program
- Inspect the space around the equipment
- Where Can You Get Covered Medical Items?
Ideally, hospitals and other medical facilities can purchase covered medical supplies through a group purchasing organization or negotiate directly with distributors or wholesalers, all of whom are doing a larger share of their business online.
- Does Insurance Cover CPAP Machines And Supplies?
Yes, most insurance plans partially cover the costs of CPAP machines and related equipment. Often the machines themselves are covered to an extent, but you may be responsible for other components such as tubing. Sometimes replacement parts are covered, with a limit to how many replacement parts can be purchased annually. Many insurance providers require you to meet your annual deductible before covering your CPAP equipment.
- What Medical Equipment Does A DME Provider Offer?
The typical CPAP equipment setup includes a main machine and several accessories. Some of them are permanent, while others wear out and are replaced regularly.
- PAP machine: This could be a CPAP, BiPAP, AutoPAP, or ASV device. Most of them are equipped with built-in humidification, digital compliance chips, and CPAP filters.
- PAP filters: Additional disposable filters are also needed, as PAP setups use a 2-filter system.
- CPAP tubing: This is the coiled hose used to deliver the pressurized air from the machine to the mask.
- CPAP mask: This could be a nasal pillow, nasal mask, or oronasal (full face) mask.
- Headgear: This is how the mask is secured for use.
- Chin support: This is used to prevent mouth breathing, to ensure that PAP therapy is effective.
Some patients may also require additional supplies and equipment
- What Is A CPAP Machine And How Does It Work?
A CPAP (continuous positive airway pressure) machine sits next to your bed as you sleep. The machine attaches to a mask that you wear over your nose, mouth, or both, and delivers pressurized air throughout the night to keep your airway open.
Once you’re prescribed CPAP therapy, your doctor will encourage you to use the machine every night for best results. A CPAP machine’s compressor (motor) generates a continuous stream of pressurized air that travels through an air filter into a flexible tube. This tube delivers purified air into a mask that’s sealed around your nose or mouth.
As you sleep, the airstream from the CPAP machine pushes against any blockages, opening your airways so your lungs receive plenty of oxygen. Without anything obstructing this flow of oxygen, your breathing doesn’t pause. As a result, you don’t repeatedly wake up in order to resume breathing
- Does Your Deductible Apply To CPAP Equipment?
Notably, your deductible applies to essential CPAP equipment, not including optional accessories. A good number of providers have replacement schedules for components such as tubes, masks, and filters that indicate how often replacements are covered. If you need more frequent replacements of certain components, those costs may be out of pocket.
- What Are Those Noises Your CPAP Machine And Mask Are Making?
Sounds occur when there is a leak at the mask site, when the seal is not quite complete, usually near the eye or mouth, or from the exhalation port. The most common type of leak problem concerning a CPAP mask is a seal leak. This occurs when the air inside the mask is leaking out between the mask and the facial skin.
- Does Medicare Cover CPAP Machines?
Yes, Medicare considers CPAP devices to be durable medical equipment and provides 80% coverage under Part B as long as you meet certain conditions. However, your doctor must first diagnose you with obstructive sleep apnoea following an approved laboratory sleep study or an at-home sleep study, and give you a prescription for a CPAP machine. Then, Medicare covers a 12-week initial period of CPAP therapy for obstructive sleep apnoea, as long as you meet the requirements.
- What Are The Codes For CPAP And Supplies?
- E0601: CPAP Machine
- A7034: CPAP nasal mask
- A7032: CPAP nasal mask cushion
- A7030: CPAP Full Face mask
- A7031: CPAP Full Face mask cushion
- A7044: CPAP Full Oral Interface
- A7046: CPAP Humidifier Chamber
- A7037: CPAP tubing, long and short hoses
- A7038: CPAP disposable filter
- A7039: CPAP foam filter
- A7035: CPAP headgear
- A7033: CPAP replacement nasal pillows
- A7036: CPAP chinstrap
- E0561: CPAP Passover Humidifier
- E0562: CPAP Heated Humidifier
- E0470: BiPAP Machine
- E0471: BiPAP-ST
- A4604: Integrated Heated CPAP Tube
- K0553: Oral/Nasal (Hybrid) Mask
- K0554: Cushion for Hybrid Mask
- K0555: Nasal Cushion for Hybrid Mask
- Where Can You Buy CPAP Supplies?
There are three main ways you can source and purchase your CPAP equipment and supplies: through a DME provider, an online CPAP supply store, or a large discount retailer.
- At What Severity Will Insurance Cover CPAP For Sleep Apnoea?
In the United States, many commercial insurances are starting to follow Medicare’s guidelines for CPAP coverage. However, most insurance companies will authorize payment for CPAP if your AHI is moderate to severe. In order for Medicare to coverage CPAP for sleep apnoea, the patient must meet one of the following criteria for obstructive sleep apnoea to be diagnosed:
- AHI or RDI must at least 15 events per hour (read more about the other Medicare requirements for CPAP coverage here).
- AHI or RDI greater than or equal to 5 and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness (EDS); impaired cognition; mood disorders; insomnia; or documented hypertension, ischemic heart disease, or history of stroke.
What Is The Difference Between CPAP And Bipap Machines?
CPAP machines are known to have an adjustable pressure setting that delivers between 4 to 20 cm H2O (a measure of air pressure that stands for centimeters of water pressure) regardless of whether the user is inhaling or exhaling.
BiPAP machines meanwhile have two pressure settings — inhalation positive airway pressure (IPAP) and exhalation positive airway pressure (EPAP) — that allow for lower pressure levels during exhalation. Depending on the BiPAP machine’s settings, the switch between IPAP and EPAP may be timed or automatically based on the user’s breathing patterns. BiPAP machines have a typical pressure range of 4 to 25 cm H2O.
While CPAP machines have only one setting; some models now have sensors that allow for gentler air pressure on the exhale. Unlike the EPAP setting on BiPAP machines, the exhalation pressure cannot be set by the user and is only slightly less than the overall pressure setting.
- What Does A CPAP Machine Do?
A CPAP machine is the recommended treatment for Obstructive Sleep Apnoea (OSA) by the American Academy of Sleep Medicine and can be prescribed by a board-certified sleep specialist or other licensed health care providers. A CPAP machine provides a constant stream of pressurized air to your nose and/or mouth, which keeps your airway from collapsing while you sleep. This helps you breathe and maintain good blood oxygen levels throughout the night.
- What Do Your CPAP Readings Mean?
The AHI number indicates how many apnoea events (how many times you stop breathing) you have per hour. An AHI reading under 5 is considered normal. A reading of 5-15 apnoea events indicates mild sleep apnoea. Readings of 15-30 are considered moderate sleep apnoea. If your AHI is 30 or more, it is considered severe sleep
- How Much Will I Pay For CPAP Equipment?
Note that most CPAP machines fall in the $500 to $800 range, however. BiPAP (Bilevel Positive Airway Pressure) machines are more complex and tend to cost more as a result. Most BiPAP machines cost $1,000 to $3,000, but some can run as high as $6,000. These prices don’t include accessories.
- Why Does Your Insurance Require Proof Of Usage?
Have it in mind that your insurance company wants to make sure that you are using the device on a regular basis to improve your health. They do not want to pay for a device that you are not using. Therefore, many insurance companies that pay for CPAP on a rental basis are now requiring proof of compliance in order to continue the device rental or before they will purchase the device for you
- Should I Pay Cash For CPAP Machine And Supplies?
Of course! Most providers offer cash rates for PAP devices and replacement supplies. You may save money and you will definitely save the hassle of dealing with your insurance company. A prescription from your physician and recent sleep study report are still required even for cash purchases.
- How Can You Find A CPAP Supply Provider That Is Considered In Network With Aetna Insurance?
There are a few ways to get reliable information about what CPAP providers is in-network with your insurance:
- Use Health Sqyre
- Visit Medicare’s Website
- Contact Your Insurance Company
- How Much Do CPAP Machines Cost?
A CPAP machine’s cost can range anywhere from $250 to $1,000 or more, with prices generally rising for machines with more advanced features.
- Will Your Insurance Company Require Authorization For Your CPAP?
Note that many insurance companies, including Medicare and PPO plans, are now requiring authorizations for more and more services, including sleep studies and PAP devices. Many device providers will request authorization from your insurance company if needed.
In addition, they will usually require a prescription and your most recent sleep study showing a diagnosis of sleep apnoea. If you’re a current CPAP user and are getting a replacement device, you may need a new sleep study. Typically, insurance companies will require a new sleep study every three years.
- How Often Will Your Insurance Pay For A New Device?
Many insurance companies will cover a new device every three to five years. You may also need a new sleep study before your insurance company will authorize the new device. Note that the insurance companies want to make sure that you still need the device and that your current settings are appropriate. Due to weight loss or gain or other changes to your health, you may require a higher or lower pressure setting.
- How Often Will Your Insurance Pay For Replacement Supplies?
Generally, insurance companies will authorize the replacement of CPAP masks, tubing, and filters every 90 days. Many insurance plans follow the guidelines from Medicare for regular replacement of supplies
- When Was The Last Time You Got A New CPAP Mask?
Why you should replace your mask is about much more than just issues of sight and smell (although those are more than reason enough!). Replacing your mask regularly will ensure that you enjoy the full benefits of CPAP therapy. No matter which type of CPAP mask you use, it is recommended that you replace the mask cushion (the part that directly contacts your face) once or twice a month, and replace the entire mask at least once every six months.
- Do You Need A Prescription For A CPAP Machine?
Yes, you will need a formal prescription from your doctor before you can buy a CPAP machine. Although CPAP therapy is relatively safe and one of the most effective ways to treat the symptoms of sleep apnoea, you’ll need to make a trip to the doctor’s office first.
- How Can You Make The Most Of Your DME Provider?
The DME does more than just set you up with your PAP therapy.
- PAP education: Aside from setting you up with your medical equipment and supplies, they teach you how to use your devices, help you to find ways to adjust to therapy even days or weeks after starting it, and provide you with tips and tricks for making it work for you if you are having problems with CPAP.
- Supply replenishment: While the PAP machine itself should last several years, the rest of the parts have limited life due to normal wear and tear. Your DME is prepared to help keep your CPAP masks, tubing, and CPAP filters up to date. With some DME providers, you can even set up automated messages in email to remind you to replace certain CPAP supplies that are expected to have worn out.
- “SOS” calls: The DME exists to help you succeed with your PAP therapy. If you are struggling with your pressure settings, or have a head cold or allergies and CPAP has become intolerable, or if you dislike your mask or find you take it off more than you keep it on… for any of these reasons, you are encouraged to contact them to help you when you have CPAP problems.
- Insurance and fee schedule questions: If you are unclear how frequently you need to replace DME supplies, your DME can give you advice based on what your insurance payer recommends. Medicare guidelines about your PAP-related medical supplies are also a big part of the DME’s knowledge base, as are DME fee schedules for paying for equipment, regardless of insurance status. If you have a question about your hardware and supplies, about a Medicare DME fee schedule, or about insurance coverage in general, the DME can find the answers you need. It’s as easy as a phone call.
- What Is The Difference Between Device Rental And Purchase?
Many insurance companies now pay for PAP devices on a monthly rental basis, typically 3 to 10 months. At the end of this period, you will own the device. Because it is a monthly rental, your provider will bill your insurance company monthly. If you have a co-insurance, you will also be billed monthly.
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