Does Your Insurance Cover Home Sleep Apnea Testing?
Don't overlook your insurance benefits
If you find yourself with symptoms of a sleep disorder and your doctor refers you for a sleep study, almost all insurance programs will cover all or most of the cost. Some plans like Medicare and Medicaid, also cover a home sleep apnea test, a secondary option for determining sleep apnea in patients with high probability.
But how does the Affordable Care Act impact sleep testing?
The Affordable Care Act allowed insurance will continue to cover sleep testing as long as it is prescribed by a physician. The only costs patients have to pick up are the deductible and co-pay as designated in their insurance plans.
The biggest most notable change is the shift in the healthcare industry towards results-oriented treatment. This incentivizes insurance providers and patients to look at home sleep apnea testing (HSAT) as an option for diagnosis instead of the standard in-lab test. We've previously discussed the pros and cons of home sleep apnea testing vs. an in-lab study here. While home sleep apnea testing is indeed a cheaper alternative to an in-lab test, not all patients, especially those with complicated sleep conditions like respiratory failure or other comorbidities, can use HSAT as an option.
If you have recently been evaluated for sleep apnea
Most insurance providers now require authorization for in-lab sleep studies and for home sleep apnea testing. That's why it's important for physicians to indicate medical necessity so the patient doesn't have to go back-and-forth between healthcare providers in order to be tested.
If you've already been diagnosed with sleep apnea
The good news is that under the Affordable Care Act insurance providers are not allowed to discriminate against people with preexisting conditions, including sleep apnea. In addition, patients cannot be denied coverage or charged more because of their diagnosis of sleep apnea.
A PAP machine is considered durable medical equipment (DME), which means it may be subject to a new tax under the Affordable Care Act. Patients with Medicare are able to test a PAP machine for three months, and if the results are shown to be beneficial, Medicare will rent it for a period of 13 months prior to purchasing it.
Most insurance plans will continue to cover the costs of a PAP machine, but will require proof of patient compliance from the equipment provider before they pay for on-going device rental, purchase or additional replacement supplies.
In fact, most insurance compliance guidelines require that you show proof of using your device for a minimum of 4 hours per day at least 22 days out of a consecutive 30 day period within the preceding 90 days (in the past 3 months).
Tips to ensure success
Make sure to inform yourself and your patient regarding what their insurance will cover for their sleep testing and office visits. Monitoring and measuring PAP compliance, and assisting patients to achieve good compliance, is also an important part of making sure that your patients are getting the treatment they need.
To learn more about home sleep apnea testing and its affects on providers and payers check out our CEC-eligible online learning module here.
To learn more about maximizing PAP adherence: check out our free e-book here!