Insurance Coverage

Fortunately CPAP machines and supplies although essential and not covered by Alberta Health Services are often covered by your private health insurance provider. Coverage may vary depending on the provider as well as your group plan with respect to requirements and amount and frequency covered. Therefore it is important to contact your provider to see what their requirements are.

Below are some helpful tips regarding insurance coverage, should you have additional questions please contact our office at 1-888-286-2318 and we will be happy to help.

 

---

 

What will my insurance cover?
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 doctor prescribes equipment and supplies to treat that disorder. The equipment and supplies typically must be “medically necessary” for insurance to provide a benefit. This may require written documentation from your doctor over and above a normal prescription. Dream Sleep Respiratory will help ensure that your doctor supplies the necessary documentation to support the benefit paid by your insurance.

 

---

 

When can I get replacements for the equipment and supplies?

CPAP and humidification are typically prescribed the first time you are diagnosed with a sleep disorder. Since sleep disorders are often 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 …) Each insurance company will have a “frequency” schedule that identifies how often the insurance company benefit can be used. For instance you may be eligible for a new mask every 6 months. 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.

 

---

 

Talking with your insurance company about CPAP coverage.

• Be sure to have the exact name, model number and brand of the equipment (CPAP and humidifier) recommended to you.
• Know the name, model and brand of mask that has been recommended.
• 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.
• After confirming CPAP coverage ask them what information is required to be provided for reimbursement ( prescription, sleep study, study interpretation, quote, receipt, etc.)

---

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 want 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?

1. How often can I get a new:

• CPAP machine?
• Humidifier?
• Mask?
• Replacement pieces and parts?

1. What do I need to do if my equipment needs repair?
2. Are there rules related to “extras” or upgrades? What do I need to know about that?
3. Would you send me the specific policy related to CPAP benefits?