Managing a Sleep Disorder Long-Term: Will Insurance Cover Your Expenses?
Both private and public insurance plans cover CPAP machines and accessories.(HOWARD SANDLER/ISTOCKPHOTO)Insurance coverage for sleep disorders is a mixed bag. If you have obstructive sleep apnea, you're in luck. For other disorders which require medication—or even more complicated behavioral therapy—approval can get iffy.
If you have symptoms of a sleep disorder and your doctor refers you to a sleep study, almost all insurance programs will cover all or most of the cost. Several plans, including Medicare and Medicaid, also recently agreed to cover home sleep tests, a secondary option for sleep apnea diagnosis.
Deciding between a sleep lab study and home test may be a matter of financial choice; often, you'll be covered for a lab study but not for a home test. But if your plan has a high deductible, the pricier lab study may cost more anyway. In-lab studies are more comprehensive, however, and should be your first choice, so talk to your doctor about payment options.
Sleep apnea treatment
Both private and public insurance programs cover CPAP (continuous positive airway pressure) machines, which force air into your lungs and keep you breathing, uninterrupted, while you sleep. Depending on the machine's life expectancy, insurance will also cover replacement of masks, tubing, pads, and most accessories at least twice a year. And more sophisticated machinee sophisticated machines —such as a BiPAP (bi-level positive airway pressure) or APAP (autotitrating positive airway pressure)—are typically covered if you've tried and can't tolerate the less expensive CPAP.
If you opt for surgery, you may be required to provide documentation of your sleep apnea score and time spent on a CPAP machine. (Since CPAP is the recommended first option, companies want to make sure that you've at least tried that first.) Not all procedures are covered, according to the American Sleep Apnea Association; but an appeal that demonstrates your need for a specific operation may change your provider's mind.
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Next Page: Medication [ pagebreak ]Medication
Because prescription plans vary widely, so do the costs of medication. The amount covered depends on what type of drug you're taking and whether you use brand name or generic. Insurance typically picks up at least part of the tab for prescription sleep drugs, as well as medications for restless legs syndrome, narcolepsy, and off-label hypnotics and antidepressants.
But for medications that are only approved for short-term use, your insurance company may decide—even before your doctor does—when you've had enough. After a few months of recurring prescriptions, patients often find themselves switching to cheaper generic medications, or turning to long-term behavioral treatment.
Many plans do not cover cognitive-behavioral therapy for insomnia, or group it into their mental health benefits category. Others may reimburse for all or part of your sessions. Patients who can't afford sessions out-of-pocket may want to try less expensive options like group therapy, telephone sessions, or Internet counseling.
The good news is, as sleep disorders become more prominent and the science behind them becomes more well-known, insurance companies are increasingly more likely to cover treatments for all of these conditions.
A decade ago, most insurance companies didn't even cover sleep studies, says Meir H. Kryger, MD, director of sleep medicine research and education at Gaylord Hospital in Wallingford, Conn. "Now everyone seems to have a relative with sleep apnea," he says. "The only time you have problems with it is when someone has no health insurance at all."