Deductibles

The deductible is the amount you pay out of pocket for medical expenses before your insurance company’s coverage kicks in. For example, if you have a deductible of $1,000 and you haven’t had any other services performed before your sleep study, you will typically need to “pay down” that $1,000 deductible before insurance begins to pay. After that, your insurance company begins to reimburse depending on your policy, whether you’ve stayed “in network,” and subject to your coinsurance. The cost of your sleep study will be determined by the allowable amount set by your insurance provider. The benefit to the patient is the amount of the sleep study that will go toward your deductible. This is a great option if you require additional testing or therapy.  

Coinsurance

This is the percentage you will still pay on medical services after the deductible has been satisfied. Usually, this is an 80/20 split — insurance pays 80 percent of the final bill and you pay the rest up to a predetermined maximum. Check your policy for your coinsurance percentages.

Copayment

Copayment (or copay) usually applies to prescriptions and office visits, but some insurance companies may ask you to pay a small fee (copay) before getting a sleep study. You will need to consult your insurance carrier to see if they have any front-end fees you’ll need to pay first.

Out-of-pocket limits

This refers to the total amount you will pay for covered expenses in any given year. First, you pay your deductible, then you pay your coinsurance percentage up to a predetermined amount. After you reach that limit, you have maxed out your out-of-pocket, and your insurance company usually covers all expenses at 100 percent.

Here’s a tip: Pay attention to the scheduling of your sleep study as it relates to your deductible. Having a sleep study done at the beginning of your calendar year plan can be costly, but once you pay your deductible, coinsurance can cover a majority of your sleep study and durable medical equipment (DME) expenses and bring you closer to your overall out-of-pocket expenses limit, leaving the rest of your healthcare costs to be covered at 100 percent.

Having a sleep study at year’s end, on the other hand, means you may have already reached out-of-pocket limits due to other medical costs. You will want to get your sleep study and DME expenses covered and updated at the end of your calendar year or you’ll need a plan to pay toward your deductible the following year.

Will Your Insurance Pay for Your Sleep Study?

Insurance is inherently complicated, especially when dealing with specific kinds of medical procedures and tests.

So the question remains…

Does health insurance cover sleep studies?

Yes. Well, usually. The less-than-satisfactory answer is, “It depends.” But by and large, all insurance payers offer some sort of reimbursement for sleep studies of all kinds. This is one of the main questions we field from patients at Sleeptopia. 

What is the cost of a sleep study with insurance?

It’s nearly impossible to capture all of the variations in reimbursement schedules from one insurance payer to the next, especially with so many different avenues for applying insurance benefits. However, here are some highlights and generalized guidelines for determining if, how and when your insurer will cover your study. For this explanation we will use private insurance carriers and not CMS/Medicare/Medicaid.

Simplifying insurance coverage for sleep studies

Understanding what’s covered, what’s not, how much, and when demands some mastery over your policy’s terms and conditions. These include an insurer’s specific testing protocols, network discounts, deductibles, coinsurance, copays, and out-of-pocket limits. But here, we’ll help make it a little easier. 

Insurance requirements for sleep studies

Don’t be surprised if your sleep test is different from your aunt’s or co-worker’s — the choice is often dictated by the insurance company. There’s a wide range of rules for what insurance carriers will cover with criteria to be met to approve claims. For example, some insurers require you to have a less-expensive home sleep apnea test (HSAT) first. HSATs can accurately diagnose the majority of patients with sleep apnea, meaning an overnight sleep study isn’t required for a diagnosis and treatment. This protocol saves patients and insurance companies money and speeds up the process for patients when sleep apnea is the expected outcome.

The “network” rule

Insurance companies often have networks of approved doctors who can offer patients discounted rates on services. Patients can save more money by selecting doctors inside these approved networks. The prices of tests are going to be less “in-network” for both the patients and the insurance companies as a result.

But patients aren’t required to use these networks. They are still given the option of seeking “out-of-network” physicians and sleep labs. Reimbursements can be slim to none for these doctors and sleep labs hence the “in-network” carrot that insurance companies dangle. Sleeptopia has in-network status with majority of insurance carriers. If you’ve been referred to Sleeptopia for a sleep study, we will perform a prior authorization before rendering service; however we still believe it’s in your best interest to consult with your insurance company first to confirm the cost and deductible amount for the sleep study. 

Deductibles

The deductible is the amount you pay out of pocket for medical expenses before your insurance company’s coverage kicks in. If you have a deductible of $1,000 and you haven’t had any other services performed before your sleep study, you will usually need to “pay down” that $1,000 deductible. After that, your insurance company begins to reimburse, with those amounts depending on your policy, whether you’ve stayed “in-network” and whether you have coinsurance.

Coinsurance

This is the percentage you will still pay on medical services after the deductible has been satisfied. Usually, this is an 80/20 split — the insurance company pays 80 percent of the final bill, and you pay the rest up to a predetermined maximum.  Check your policy for your coinsurance percentages

Copayment

Copayment (or copay) usually applies to prescriptions and office visits, but some insurance companies may ask you to pay a small fee (copay) before getting a sleep study. You will need to consult your insurance carrier to see if they have any front-end fees you’ll need to pay first.

Out-of-pocket limits

This refers to the total amount you will pay for covered expenses in any given year. First, you pay your deductible, then you pay your coinsurance percentage up to a predetermined amount. After you reach that limit, you have maxed out your out-of-pocket, and your insurance company usually covers all expenses at 100 percent.

Here’s a tip: Pay attention to the scheduling of your sleep study as it relates to your deductible. Having a sleep study done at the beginning of your calendar year can be costly, but once you pay your deductible, coinsurance can cover a majority of your sleep study and durable medical equipment (DME) expenses and bring you closer to your overall out-of-pocket expenses limit, leaving the rest of your healthcare costs to be covered at 100 percent.

Having a sleep study at year’s end, on the other hand, means you may have already reached out-of-pocket limits due to other medical costs. You will want to get your DME expenses covered and updated by the end of your insurance Calendar year or you’ll need a plan to pay toward your deductible the following year.

What if you don’t want to pay with insurance?

Sometimes patients review their coverage then look at their cash pay options and decide to skip insurance coverage because it’s less expensive to pay cash. We offer a cash pay rate that’s discounted for this reason. People without insurance can also enjoy the cash-pay discount for services we provide.

What happens if my insurance carrier refuses to reimburse for my sleep study?

This rarely happens! But is the main reason why we perform a prior authorization before service to limit this from occurring. If they decide your sleep study is “medically unnecessary,” even if your doctor thinks otherwise. This is often why the “HSAT first, PSG second” model is so prevalent. Insurance companies are trying to reduce costs, so they will demand less expensive tests upfront. But, a home sleep test may not only show you have sleep apnea, but it might also show a need for an overnight test called a nocturnal polysomnogram to measure the severity of apnea or other symptoms. In this case, the insurance payer has the proof it needs to approve and pay for a test deemed to be of “medical necessity.”

Proving medical necessity

Keep in mind that while there are textbook ideas about conditions like sleep apnea, patients are unique and rarely fit the mold. Insurance companies know this and require a great deal of information about you as a patient in their decision whether to reimburse you for a study. Proof of medical necessity is a critical part of their analysis.

They look at other health conditions such as preexisting cardiovascular disease, for example,  and past medical history, like triple bypass, for instance, to determine the kind of test you will receive. Not all tests are right for all patients. Certain patients will not qualify for HSAT if they meet other criteria. 

Still uncertain about your coverage? Call your insurance company and ask them what you need to show to receive approval for a sleep study.

How can Sleeptopia help?

We can verify insurance coverage and make pre-authorizations in our office to ensure you will receive the reimbursements your policy covers. You can also ask us about your options and what to expect before your sleep study so there won’t be any big surprises.

Sometimes a sleep study can elicit more anxiety due to its costs than to the mystery surrounding the test itself. Sleep studies can be expensive, but they don’t have to be. You simply must have a solid understanding of your health insurance coverage and options.

Remember, the price of a sleep test and therapy may be more than you’d like to pay now, but it’s nothing compared to the price you’ll eventually pay for untreated sleep apnea or other disorders — not only in dollars but in quality and length of life.

NO MEDICAL ADVICE

The information supplied through or on the Website, or by any employee or agent of Sleeptopia, whether by telephone, email, letter, facsimile, or other form of communication, is for informational purposes only and does not constitute medical, legal or other professional advice. Health-related information provided through the Website is not a substitute for medical advice and should not be used to diagnose or treat health problems or to prescribe any medication, medical devices, or other remedies. The information on the Website may be presented in conclusory, shorthand, or summary form and is not intended to supplant medical advice provided by your physician or other healthcare provider or any information included by the manufacturer with or on any product. The receipt of any questions or feedback that you submit to Sleeptopia does not create a professional relationship and does not create any privacy interests other than those described in the Privacy Policy. YOU SHOULD ALWAYS CONSULT A PHYSICIAN OR OTHER HEALTHCARE PROVIDER OF YOUR OWN CHOICE before making any healthcare decisions or for guidance about a specific medical condition AND CAREFULLY READ ALL PACKAGING AND OTHER INFORMATION PROVIDED BY THE MANUFACTURER OF ANY MEDICAL PRODUCTS OR DEVICES BEFORE USING THEM.

Self-pay

Sleeptopia offers Self-pay options that may be less expensive than going through insurance for your Home Sleep Study. If you have a high-deductible insurance plan and will be paying a large cost outright for your test, you may choose to pay for the test yourself without using your insurance. 

National Non-Profit Organizations Offering Assistance

There are many national non-profit organizations offering assistance for individuals with specific disorders or diseases. Unfortunately, many of these organizations do not offer assistance to patients suffering from sleep disorders. But, several organizations offer this assistance. Each of the organizations listed below offers programs that may benefit patients with sleep disorders. Please visit these resources to determine if you qualify for their programs.

• National Organization for Rare Disorders (NORD) offers co-pay and premium assistance programs for patients with narcolepsy.
• Partnership for Prescription Assistance connects patients to assistance programs for specific medications, which may include specific sleep medications.
• Patient Services, Inc. offers an assistance program for copays, premiums and ancillary services for individuals with circadian rhythm disorders.
• Rx Outreach is a nonprofit prescription program offering low-cost medications, including many sleep medications, for individuals who qualify.
• Cerner Charitable Foundation assists children 18 years of age or younger if either the child has no insurance or insurance does not cover a specific expense.

Positive Airway Pressure and Your Insurance | What You Should Know

How do I know if my insurance covers my positive airway pressure (PAP) equipment?

Most private health insurance policies cover PAP equipment. However, the level of coverage and rules for coverage will depend on your specific insurance policy. Review your insurance policy to determine if, and to what extent, your PAP equipment is covered.

Medicare generally covers a three-month trial for PAP therapy, during which your compliance and reaction to the treatment are measured. If you meet Medicare’s criteria, you will qualify to continue using your machine.

What are my purchase options?

Your insurance provider may require you to either buy or rent your PAP machine. Usually, if paying through insurance, what you pay out-of-pocket should be the same, regardless of whether you rent or buy.

Buying the machine through insurance

You may be required to purchase your machine from your insurer. This would entail paying for the machine upfront with the cost depending on your insurance deductible and out-of-pocket limits.

Renting the machine through insurance

Your insurer may require you to rent your machine instead of purchasing it outright. You would pay monthly installments on the machine for a set period, usually between three and ten months, after which the machine would be yours. This spreads your payment for the machine out over a longer timeframe so that you are not paying a lump sum upfront. This also allows the insurance company to measure your compliance during the first few months of your treatment to determine if you are using your machine. If you are not compliant over that period, your insurer may not continue to pay for the treatment and could require you to return your machine or arrange self-payment going forward.

Self-pay

Self-pay is an option that may be cheaper than going through insurance for both the machine and supplies. If you have a high-deductible insurance plan and will be paying a large cost outright for your machine, you may choose to pay for the machine without using your insurance.  Many durable medical equipment (DME) and online providers have lower prices for cash purchases versus insurance. When using this payment method, you also would not be subject to compliance criteria set by your insurer. Before purchasing your machine, research to determine if you can purchase your machine at a lower cost through different supply companies.

What is “compliance”?

“Compliance” or “adherence” are terms used to describe how often you use your machine. The Centers for Medicare and Medicaid Services (CMS) require an individual to use their machine at least four hours per night during 70% of nights for a consecutive 30-day period, during the first three months of usage. This means that in 30 days, you must use your machine for at least four hours on at least 21 days during that time. Many private insurers mimic CMS guidelines, but you should check directly with your insurer to determine your specific compliance requirements.

Once you begin using your machine, your usage data is collected and is either remotely transmitted to the DME company or physician/office where you obtained your machine or is downloadable from a memory card in the machine. This information is shared with your insurance provider for them to determine whether you are compliant with usage requirements.

If you are not compliant with your insurer’s requirements, meaning you are not using your machine enough, your insurer may stop paying for your machine, supplies and/or other sleep care services. If you are currently renting and do not own your machine, your insurer may require you to return the machine. You may then have to pay for a machine and/or supplies out-of-pocket to continue your treatment.

What else should I be aware of?

Purchasing supplies

You will need to purchase supplies for your machine, including a mask, hose and more. Supplies may be partially covered by insurance if you remain compliant, but they may be cheaper if purchased without insurance.

Comparing prices

Just like with any other product or service you purchase, you should price shop different DME providers, both in-store and online, and with or without insurance to find the best prices for your machine and supplies. Depending on your co-pay, deductible and out-of-pocket limits, it may be cheaper to purchase your machine and/or supplies outright instead of going through your insurance. Different equipment providers may also charge various prices for the same equipment or supplies.

Talking with Your Healthcare Provider

When prescribed your treatment, talk with your physician regarding all treatment options to see if there are lower-cost options or if there are any assistance programs available. Also, if you have any issues with your treatment, talk to your healthcare provider right away. For example, if you cannot tolerate using the machine at night or your mask does not fit properly, you should talk with your physician’s office to troubleshoot these issues so you can ensure you are effectively treated and able to use your machine long-term.

Disclaimer: The information provided in this resource applies to the United States only and may not reflect practices in other locations.

Financial Policy

While we do prioritize our patients’ needs, it is important to understand that you are responsible for payment by Sleeptopia Inc and affiliates’ terms. Assignment of benefits to a third party does not relieve the patient of the obligation to ensure full payment. Billing third-party payers is not an obligation but rather a service we offer if all necessary billing information and signatures are provided.

Medicare 

We may accept Medicare assignments, billing Medicare directly for 80% of allowed charges and billing the remaining financial responsibilities to additional insurance or the patient directly. You are responsible for providing our billing department with all necessary insurance information. We offer Electronic Claims Transmission for courtesy billing on unassigned orders. Presentation and verification of your Health Insurance Card are necessary.

Medicaid 

We may provide equipment to Medicaid recipients upon verification and approval of coverage status and medical justification. Presentation and verification of your State Beneficiaries Identification Card and personal ID are required.

Private Insurance and Managed Care 

We may bill private insurance carriers upon verification and approval of coverage status and medical justification. You are responsible for providing our billing department with all necessary insurance information. Presentation and verification of your insurance card and personal ID are required. 

Estimating Costs 

As a service to you, we will send your bill for services directly to your primary and secondary insurance companies. Additional supplies and services may be necessary, and the total cost increases accordingly. It is important to know that some insurance companies do not pay the exact amount for services that are billed. We attempt to provide you with the most accurate estimate of the charges that you are responsible for before services are rendered, but please be aware that after insurance processes your claim, your patient responsibility portion may be different from the estimate provided. 

Payment

Before receiving products, Sleeptopia requires a form of payment on file to satisfy any balances that are not paid by your insurance. This will include the patient portion of rental charges incurred in future months. We accept Visa, MC, AMX, Discover and electronic checks. All information is securely stored on our PCI-compliant merchant processor.

We provide equipment upon approval and authorization from the managed care representative. Presentation of your insurance card may be necessary. Remember, billing third-party insurance does not guarantee payment. Financial responsibility remains with you, the patient.

Ordering, Shipping, Returns, Exchanges and Warranty

If you are not happy with your purchase for any reason, we will be happy to accept a return for any unopened and unused products. We do not accept exchanges at this time, except for CPAP masks. You may return your purchase within 30 days of your original order. Items being returned must be in their original condition with the tags. Customers are responsible for a 20% restocking fee.

Guarantee Policy

Not satisfied with your CPAP mask? We offer our customers a 30-day satisfaction guarantee on our masks. This guarantee gives you 30 days for one mask exchange.

30-Day Mask Satisfaction Guarantee!

It can be difficult to estimate the sizing needed for a new CPAP mask, and it can also be difficult to adjust to sleeping while wearing one. As such, we offer our customers a 30-day satisfaction guarantee on our masks. This guarantee gives our customers 30 days to exchange their CPAP Mask once (1) per the lifetime of the customer. This trial period will allow you time to get a feel for your equipment, ensure proper fit, and test the comfort level and mask quality. In the event the mask does not meet your expectations, we will allow it to be exchanged for the mask and size of your choice within 30 days from your date of purchase.

Mask exchanges must be received at our facility within the 30-day exchange period. Please contact us before sending your mask for a unique identifying number that will allow us to correctly recognize and sort your exchange promptly. Please include a copy of your packing slip and confirmation number with your returned mask in the packaging when shipped back to us. We will provide an exchange within 10 business days of our receipt of your returned equipment.

Once your mask exchange has been approved and previous mask has been received we will send out the other mask.  

*If the price of the mask you requested when using our mask exchange program is less than the original price you paid, you will receive the price of the new mask only, minus the cost of shipping from the original order, in the form of a credit. 

This 30-day guarantee applies ONLY to our masks. Any other items purchased at the same time as your mask will be subject to the General Return Policy listed above.

IMPORTANT: Mask exchanges must be sent back in the original manufacturer packaging including all papers, instructions and parts. Failure to return the original mask with all of the parts and components will result in a denial of the exchange. 

Note: Sleeptopia will handle each exchange on a case-by-case basis with the right to decline if the customer is taking advantage of the exchange program.

Additional notes

• Delivery and shipment times are not guaranteed, they’re estimates. 
• CPAP are medical devices that require a prescription and, therefore, carriers must receive signatures for deliveries of these orders.
• A signature is also required for all orders over $500.
• Orders over $500 cannot be shipped to a PO box.
• Sleeptopia aims to quickly resolve any issue related to lost, stolen or misdelivered packages by working closely with the shipping company.
• Sleeptopia reserves the right at any time after receiving your order to accept or decline for any reason.
• If Sleeptopia cancels an order after you have paid, we will promptly refund the paid amount.
• Weather delays and other circumstances may impact delivery time.
• For shipping-related questions or concerns regarding the status of your order, please contact Sleeptopia at 1-316-573-5699 or email at help@sleeptopiainc.com.