Insurance and the CPAP Machine

The time of year that you are diagnosed with sleep apnea can have a significant effect on how much you may end up paying for your CPAP machine. Here’s how it works.

After the sleep study, you are fitted for a mask and machine by a Respiratory Therapist (RT) at the Durable Medical Equipment vendor (DME). You will likely be offered a monthly rental, where you rent to own a CPAP machine over the course of 12 or 13 months. Since you’ve probably already blown through most if not all of your copay for the insurance with the sleep study, the monthly rental fee will seem small and reasonable during the month that you start the contract.

Masks, hoses, chin straps, etc., are all paid with a per-instance fee through insurance during the month in which they are acquired. You pay whatever portion your insurance makes you pay for these extra paraphernalia. However, if you got tested in October, your copay probably starts all over again in January. You end up paying a lot more for the monthly rental in January and following months because of the copay. Even if you start in January, with a thirteen-month contract, DME’s fairly bludgeon patients into that little “gotcha” whether you like it or not.

For many of us, if you are acquiring a CPAP machine in the last quarter of any insurance year and you know you’re going to use it, it’s a lot more cost-effective just to buy it out-right than it is to buy it on contract. If you buy the machine near the beginning of an insurance year, you could start with a rental contract. (I’ll talk more about pros and cons of renting later.)

Every CPAP machine has the ability to record what is called ‘compliance data’. It’s basically a short string of characters or numbers that lets the insurance company know how many hours you have used the machine and whether or not you have used it nightly. Make sure you spend no less than four hours every 24 hours using the machine. If you have a mask phobia or you end up removing the mask after an hour or two while unconscious in your sleep, many of us have found it easier to start wearing the mask while reading or watching the TV during the day to get used to having it on. That counts toward part of your four necessary compliance hours too. Sooner or later, as you get used to using it, you’ll be able to fall asleep wearing the mask.

In three months, when you have enough compliance data to prove you’re a faithful user of your CPAP, approach your insurance company and tell them you wish to buy the machine outright. More often then not, if your insurance copay is paid up for the year, they’ll pay the rest of the bill, but not before they check your compliance data. They’ll probably follow up after the three months and ask for more compliance data again in order to prove you’re still using the machine, so you can’t just use the machine for three months and then put it in a closet.

And actually, if you are diagnosed with sleep apnea, think about it: your body is going through a continued cycle of oxygen deprivation every night that you don’t use the machine. You really are better off using the machine every time you sleep, whether it’s a short nap or a whole night.

Most DME’s expect you to do as you are told. Because patients don’t normally pay up front, you don’t get a bill until it goes through your insurance, and you get hit up later by the DME to mop up whatever your insurance wouldn’t pay. The sleep patient is one of the easiest to bully because they’re simply not all there. More often than not, your spouse doesn’t know enough to quibble for you. Get educated. Before you sign the dotted line on any contract for a CPAP machine, create a cost analysis spreadsheet. Get from the DME exactly what you will pay in writing first for every month of the contract. Cost out what your rental costs would be over the course of a year, including what it will cost after your copay restarts in January, versus just buying the machine outright. It is entirely likely that your total out-of-pocket cost–even with the insurance copay taking care of some of the rental contract–will be less expensive if you just buy the machine directly than if you rent to own.

Buying the Extra Paraphernalia

Your DME will try to set you up to buy as many hoses, masks, filters, replacement tanks, etc. as your insurance will allow. I’ve gone as much as two years without buying any new equipment except filters, and they can be bought in bulk. So long as you keep it clean, don’t mangle or damage the masks or hoses, etc., there really is no reason to continually replace perfectly useful equipment. DME’s are businesses, and they exist to sell you stuff. If they can get you used to buying stuff whether you need it or not, they will. Replace only what you need – not what they expect you to buy. That said, normal wear and tear seems to have a higher affinity for some of us than it does for others. If you have a high wear and tear affinity, you may end up needing more masks and hoses than your insurance will shell out for.

DME’s don’t want you returning masks. However, many insurance companies require DME’s to give you thirty days in which to return the product and replace it for another. Know your insurance company’s policy with the DME. DME’s will have a tendency to try to bully you into buying a new mask and may even tell you that you cannot return the old mask, even if the return policy exists. In such cases where the DME is actively hostile toward your comfort, you really are better just buying your equipment on line and getting reimbursed directly from the insurance company.

Renting vs Owning A CPAP Machine

Renting can give you the leeway to try out different machines. If money is less of an object for you, there is no harm in renting. In fact, there can be benefits. For instance if you find you don’t like the loudness of a particular machine, you can try a different machine – even a different make and model. However, since you would be turning in a used machine back to the DME,  they have the option of giving you, in turn, a different machine that is also used. In other words, switching machines doesn’t guarantee you’ll get another brand-new machine. You may also find you hate the new machine.

Some people toss and turn radically while they sleep. I’ve heard of people whipping their machine by the hose off the nightstand into the wall or across the bed, often damaging the machine or startling a spouse, all while entirely unconscious. If you are a ‘chucker’, you would be able to return the machine and get a replacement from the DME probably the same day. If you own the machine, you end up having to buy a new machine, or get the one you own fixed – and that can take precious nights of sleep deprivation.

As far as I know there is no ‘renting’ or ‘lending’ of masks from DME’s. You’ll have to join a CPAP support group to find other people willing to switch or try out masks. Some support groups even start ‘lending libraries’ of masks, hoses and even oximeters for their members.

Owning can be good if you are fairly careful with your machine, you know you’re going to use it, and you’re happy with its capabilities. As pointed out earlier the biggest benefit is the considerably-reduced cost of owning vs. renting.

In a future post, I’ll talk about what machine I got, how I got it, and why you should seriously research the best machine for yourself before buying any machine or signing any rental contract.

CPAP – Continuous Positive Airway Pressure – a method of air delivery to the lungs – also synonymous with the machines that provide the same.
DME – Durable Medical Equipment – the stuff we buy from a DME vendor. DME often means ‘DME vendor’ too.
RT – Respiratory Therapist

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