How Often Does Insurance Cover a New CPAP Machine?

If you’ve been diagnosed with sleep apnea, it’s likely that you’ll need a CPAP mask, as this is considered the best course of treatment for the condition.

However, you’re probably wondering about insurance.

Usually, your insurance company will cover the cost of your CPAP or bi-level PAP device. That said, coverage varies depending on your plan, insurance company, and authorization requirements.

CPAP devices are usually covered by your insurance company on a monthly rental basis, over a period of approximately 3 to 10 months. Your provider will bill your insurance company monthly, and, at the end of this rental period, you will own the device.

On the other hand, if you have a co-insurance plan, you will also be billed monthly for the rental cost of the device, alongside your insurance company.

Does Anthem cover CPAP machines?

Thankfully, the majority of Anthem Blue Cross Blue Shield PPO and HMO plans cover CPAP therapy supplies. So if you’re close to meeting your deductible, you may be able to acquire your CPAP device at almost no cost to you. 

Anthem’s insurance plans will cover CPAP supplies that are deemed a medical necessity for OSA (obstructive sleep apnea), such as:

  • PAP (positive airway pressure) Machines and Humidifiers
  • Masks and Headgear
  • Tubes and Filters

However, the cost of other accessories for your CPAP machine, including things like cleaning devices or wipes, batteries, or duplicate machines such as travel versions, will not be covered.

In order to prove your eligibility for coverage of your CPAP device, Anthem Blue Cross will require documentation such as relevant doctor’s notes, sleep test results, a prescription, and may include other documents, too.

How often will insurance pay for CPAP supplies?

Because CPAP machines and their tubing are required daily, they’re subject to significant wear and tear, so you may be wondering how often insurance will cover CPAP supplies.

Again, this will depend on your individual insurance plan and provider, but in the case of Anthem they offer the following replacement schedule:

  • Typically, filter replacements are every 30 days
  • Typically, tubing replacements are every 3 months
  • Typically, mask replacements are every 3 months
  • Typically, machines are every 5 years

Generally speaking, most insurance companies will authorize the replacement of CPAP masks, tubing, and filters every 90 days. This is because many insurance plans follow Medicare’s issued guidelines on the replacement of supplies.

If your insurance coverage covers your CPAP on a rental basis, you may be wondering how long the rental period lasts. The most common options include:

  • 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)

How often can you get a CPAP machine with Medicare?

Medicare may cover a 3-month trial of CPAP therapy, and they may cover it longer if your doctor documents in your medical record that you meet certain conditions regarding the use of the device and they claim that the CPAP therapy is helping you.

How long is a CPAP Prescription good for?

Seen as you’ll need a CPAP prescription from your doctor in order to make an insurance claim, you may be wondering how long your prescription is valid for. Your prescription may display an expiration date, in which case it will be valid until this date.

If your CPAP prescription mentions a “Lifetime Need” or says “99 months”, this means that the prescription is valid for as long as you require the therapy. If your prescription specifies a certain amount of refills, you can receive your CPAP items the number of times listed.

Can I just buy a CPAP machine?

No. In order to buy a CPAP machine, you must have results from a sleep study and a CPAP prescription from your doctor or healthcare professional.

The reason for this is that CPAP devices are a class II medical device under FDA regulation, meaning you require a prescription in order to obtain one, and in order to get the prescription, you need to undergo a sleep study and have a board-certified sleep specialist physician interpret your results and prescribe CPAP treatment before you undergo CPAP therapy.

Final Verdict

According to SoClean CEO Bob Wilkins, there are roughly 8 million CPAP users in the United States, and this is growing yearly. 

If you’re diagnosed with sleep apnea and require CPAP therapy, it’s likely your insurance will cover the cost of the device, and the replacements required thereafter.

However, how often they replace these, and how much of the cost your insurance covers, of course depends on your policy and the company you’re with. 

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