To a person living with untreated sleep apnea, going to bed at night can be frightening. Obstructive sleep apnea causes the muscles at the back of the throat to relax during sleep, obstructing the airway and stopping breathing. The person often is without oxygen for a minute or longer before the brain alerts the body to wake up and begin breathing again. Sleep apnea is very treatable, however, and many of the treatments are covered by both Medicare and private insurers.
Facts About Sleep Apnea
- About 2 percent to 4 percent of Americans have Obstructive Sleep Apnea (OSA).
- Obstructive Sleep Apnea (OSA) is a recognized medical condition and is therefore covered by most private insurance plans.
- If untreated, OSA can lead to poor sleep and reduced oxygen circulation, as well as increased risk for stroke and heart attack. It can also worsen the symptoms of high blood pressure and diabetes.
To be diagnosed with sleep apnea, a patient must undergo a preliminary examination from a primary care physician. If the physician suspects sleep apnea, he or she will refer the patient to a specialist for a sleep study. The results of the study will determine the diagnosis and treatment.
Sleep lab studies can be very expensive, typically costing around $2000 for a single night in the lab. The upside, however, is that most sleep lab studies are covered by Medicare, as well as by many private insurers.
Medicare Coverage of Sleep Studies
- Medicare payments for sleep lab testing have increased from $62 million in 2001 to $235 million in 2009, according to the Department of Health and Human Services.
- Once the annual deductible for Part B services is met, Medicare will pay 80 percent of the cost for lab testing. The remaining 20 percent must be paid out of pocket or through supplemental insurance.
- Not all sleep labs accept Medicare payments. Patients should check with their primary care doctor to ensure the lab they use is covered by Medicare.
Private insurers will usually cover the cost of a sleep test if it prescribed by a doctor and conducted at an accredited facility. Patients with private insurance should check their policy carefully; some plans offer little to no coverage for sleep disorders, while others may limit their choice of sleep specialists and testing facilities.
Home sleep tests are another option. A home test costs around $200 and allows a patient to sleep in his or her own bed instead of in a lab. This is often a more comfortable option for many patients, although home tests may not be as accurate as the tests performed in a sleep lab. Home tests are usually covered by private insurance and may be a more cost-effective option for people with large co-pay or high deductible plans.
Once a patient is diagnosed with sleep apnea, the next step is to determine a course of treatment. There are a wide variety of treatments available, and insurance coverage can vary depending on the treatment. The most common treatment for sleep apnea is the CPAP (Continuous Positive Airway Pressure), a mask-like device that pushes air into the nasal passages while sleeping.
Medicare Coverage and CPAP
- If used correctly, CPAP treatment can reduce or eliminate symptoms, leading to a more restful night’s sleep and decreased risk of serious health problems.
- Because the mask is bulky and can interfere with sleeping habits, half of sleep apnea patients stop using their CPAP within 1-3 weeks.
- Medicare will cover the cost of the CPAP as long as the equipment supplier participates in the Medicare program. Medicare will not pay the claim if the CPAP supplier is not enrolled in Medicare.
- Most private insurers also cover CPAP; the amount covered depends on the insurer. Policyholders should check their policies carefully to ensure their CPAP will be covered.
For those who find a CPAP to be too obtrusive, another treatment option is a device called Provent. Provent, which was approved by the Food and Drug Administration in 2008, is a small patch that fits over the nostrils, similar to the nose plugs worn by swimmers.
A study in the medical journal Sleep showed that people who used Provent had their apnea symptoms reduced or eliminated within three months. Provent doesn’t work on everyone, however. Lab tests have shown Provent to be ineffective on people who breathe through their mouths while sleeping, as well as people with severe nasal allergies.
While Provent may be a good option for some sleep apnea sufferers, the cost may be prohibitive. Each Provent device is worn for a single night and then discarded. A 30-day supply typically costs $65-$80, and is not covered by Medicare or private insurers, although insurance industry experts predict that it will be covered in the near future. Provent can be a cost-effective option for people with insurance plans that don’t cover the cost of a CPAP, or charge a high deductible or co-pay.
Although the cost of diagnosing and treating sleep apnea can be high, the long-term costs of not treating it are even higher. Your doctor and insurance provider can help you determine the best and most affordable form of treatment.