Machines and supplies that are prescribed to help manage sleep disorders are viewed by insurance companies as covered benefits separate from those paid to your physician or to the hospital. Most insurance companies use the term "durable medical equipment and supplies" (DME) as the separate category of benefit related to medical equipment and supplies. This means that most insurance companies have special plan rules that apply when you receive a machine and medical supplies. Machines and supplies can be costly, so most insurance plans address CPAP with a unique CPAP policy on coverage. Your member benefits department should be able to tell you specifically what your plan covers.

Tip: When calling your insurance company representative about CPAP coverage, tell him or her you are calling about your plan’s durable medical equipment and supplies benefit. Then ask about coverage for CPAP machines, masks and supplies.

Most insurance plans will pay for at least part of the cost for equipment and medical supplies when you have a diagnosis of a sleep disorder and the physician prescribes equipment and supplies to treat that disorder. You should always expect to pay a portion. The equipment and supplies typically must be "medically necessary" for insurance to provide a benefit. This may require written documentation from your physician over and above a normal prescription. Park Nicollet will help ensure that your physician supplies the necessary documentation to support the benefit paid by your insurance.

The CPAP machine starts as a rental, for 45 days (rental period may vary depending upon your individual insurance coverage), after which you will own the machine. This gives you and your physician time to be sure the machine is right for you. The mask and the humidifier are both purchased items and are not returnable for any reason other than defect.

Payment structures vary with every insurance plan. In fact, CPAP benefits may be different for every employer. Park Nicollet does not know exactly what your plan will pay for until the insurance Explanation of Benefits (EOB) is received after Park Nicollet bills the insurance company. Typically, however, payment for CPAP may be structured like this:

CPAP and other DME are used to treat certain medical conditions, just like drugs can be used to treat medical problems. Unlike prescribed drugs, however, DME is not routinely prescribed by many physicians. Your insurance company may have a single sentence in your printed member information that tells you to call your member benefits representative about specific DME coverage.

CPAP and humidification are typically prescribed the first time you are diagnosed with a sleep disorder. Since sleep disorders are lifelong conditions, you may need a new machine every few years as new technology is offered, as your condition changes, or as the machine wears out. You may need a new prescription to get new equipment under certain circumstances. Be sure you know what your insurance covers as it relates to new equipment.

Masks, pieces and parts need to be replaced frequently (they wear out, get dirty, break, etc). Each insurance company will have a "frequency" schedule that identifies how often the insurance company benefit can be used. If you need an item and it isn’t time yet for the insurance coverage, you may need to get a prescription documenting medical necessity or you may need to pay for the item yourself.

Most insurance companies have a covered benefit for only what they have determined to be medically necessary. This is usually a basic CPAP machine, humidity and mask. If you want or end up with extras, you may be responsible for payment. Many times, Park Nicollet won’t know if the insurance company considers an item an upgrade or medically necessary. As such, sometimes we ask patients to sign an “Advance Beneficiary Notice.” This document says that you agree to pay for any items not covered by your insurance company. Call your insurance company’s member benefits area and ask for coverage specific to the equipment Park Nicollet is recommending.

• When calling your insurance company representative to inquire about CPAP coverage, tell him or her you are calling about your plan’s durable medical equipment and supplies (DME) benefit. In particular, you are calling about CPAP equipment and supplies.
• Be sure to have the exact name, model number and brand of the equipment (CPAP and humidifier) recommended to you (located in your CPAP folder).
• Know the name, model and brand of mask that has been recommended (located in your CPAP folder).
• If there are specific medical or fit problems that this particular piece of equipment addresses, have that information at hand.
• Have the prescription information close at hand (located in your CPAP folder). If the member information help line doesn’t know the specifics about CPAP, ask to talk with a supervisor or the department within the insurance company that deals with DME benefits.

Questions you may want to ask your member benefits help line.

1. I have been prescribed CPAP after being diagnosed with a sleep disorder (if you know the exact name of your condition, use that diagnosis). I would like to understand what my insurance covers.
2. What is the benefit for CPAP equipment? What percent or amount does insurance pay for? What will I be responsible for?
• For the CPAP machine?
• For the humidifier?
• For the mask?
• For replacement pieces and parts?
3. How often can I get a new:
• CPAP machine?
• Humidifier?
• Mask?
• Replacement pieces and parts?
4. What do I need to do if my equipment needs repair?
5. Are there rules related to "extras" or upgrades? What do I need to know about that?
6. My health care provider has asked me to sign an Advanced Beneficiary Notice. What does that mean?
7. Would you send me the specific policy related to CPAP benefits?
8. Is Park Nicollet Health Care Products a participating DME provider for my insurance plan? If not, what should I do?