Sleep apnea is common, but insurance coverage for the condition can be confusing. Knowing what your plan covers and what your out-of-pocket costs may be can help you avoid surprises.

Insurance coverage varies by plan and provider, and often by diagnosis. Keep reading to learn how insurance providers typically cover sleep apnea tests, treatment, and related costs. For specific questions about your plan, contact your health insurance company directly.

How Insurance Covers Sleep Apnea Testing and Diagnosis

Your spouse or partner may tell you that you snore or gasp for air at night. Or perhaps you notice that you’re feeling unusually tired during the day. If you suspect you might have sleep apnea, schedule an appointment with your doctor.

Doctor Appointments

A visit with your healthcare provider is usually the first step toward a sleep apnea diagnosis. Insurance policies vary, but many plans require a $10 to $50 copayment for in-network primary care visits. Some insurance providers may charge more. A copayment, or copay, is a fixed amount you pay for the visit, while your insurance covers the remaining cost.

If your doctor suspects sleep apnea, they will likely refer you for a sleep study.

Sleep Studies

A sleep study is a test used to diagnose sleep apnea and other sleep disorders. While you sleep, sensors monitor your breathing, heart rate, oxygen levels, and other functions.

Sleep studies can be done overnight in a sleep lab or, in some cases, at home. With an at-home sleep test, you’re provided equipment and instructions by a sleep medicine specialist. You’ll then complete the test while sleeping in your own bed.

Before scheduling a sleep study, confirm what your insurance plan covers. This way, there are no surprises. Without insurance, a sleep study at a lab may cost $1,000 to $10,000. An at-home sleep test is typically $150 to $1,000.

Most Medicare, Medicaid, and private insurers cover the cost of medically necessary sleep studies. Some insurers require pre-authorization. This means your insurance company must approve the sleep test before it’s performed.

If you get a sleep study and it confirms sleep apnea, your doctor will discuss your treatment options with you.

Sleep Apnea Treatment: What Insurance May Pay For

The most common sleep apnea treatment is continuous positive airway pressure (CPAP) therapy. Your doctor may also recommend oral appliances, surgery, and lifestyle changes. The equipment or procedures you need will depend on several factors. This includes your specific diagnosis, overall health, and treatment goals. Coverage varies by insurer and plan type. But many insurance plans follow similar rules for sleep apnea treatment.

CPAP Therapy

Most insurers cover the cost of CPAP machines for people with obstructive sleep apnea (OSA). Some insurance providers require a rental period first. This period ensures that the CPAP equipment is medically necessary and used consistently. Some insurers may take back the CPAP machine if the tracking software shows the machine is not being used on a regular basis for a minimum number of hours (usually an average of at least four hours per night on 70 percent of nights).

Plans that cover CPAP machines generally also cover the supplies needed to use them. Supplies usually include a CPAP mask, tubing, air filters, and a water tank. Many of these supplies need to be replaced every two weeks to six months. If you need to replace them more often than your plan allows, you may be responsible for the cost.

Other positive airway pressure devices include bilevel positive airway pressure (BiPAP or BPAP) and auto-adjusting positive airway pressure (APAP) machines. These devices may also be covered, but check with your insurer to confirm what your plan includes.

CPAP machines and related supplies may be classified as durable medical equipment (DME) under insurance plans.

Oral Appliance Therapy

Oral appliances for sleep apnea are custom-made devices created by a dentist and worn in the mouth during sleep. Although they’re provided by a dental expert, they’re not covered by dental insurance. Because sleep apnea is a medical condition, when oral devices are covered by insurance, it’s typically through medical insurance.

For you to get coverage, your doctor may need to submit documentation to your insurer explaining why CPAP therapy isn’t appropriate for you. Some insurance plans require a cost estimate from the dentist before approving oral appliances.

Medicare coverage includes oral devices for sleep apnea. However, there are specific requirements. The device must meet the following criteria:

• Approved by the U.S. Food and Drug Administration (FDA)
• Considered medically necessary
• Supplied by a Medicare-approved provider

After meeting their annual deductible, Medicare beneficiaries typically pay 20 percent coinsurance for oral devices. It’s important to note that dental work may be needed before an oral appliance can be made. This dental work may not be covered by medical insurance

Surgical Procedures

Most insurance plans cover sleep apnea surgery, but coverage depends on the type of surgery and whether it’s considered medically necessary. Your insurance provider may require documentation first. For instance, they may need to see that other treatments, such as CPAP therapy, were ineffective. Or they may have specific eligibility requirements for certain procedures.

Even if your insurance company approves the surgery, you might have to pay out-of-pocket expenses. These expenses may include deductibles, coinsurance, hospital fees, surgeon fees, and anesthesia charges. These costs can add up, so it’s important to confirm your coverage details before scheduling surgical procedures.

Lifestyle Changes

Lifestyle changes for sleep apnea may be helpful. Depending on your provider’s advice, these may include:

• Losing weight
• Exercising regularly
• Quitting smoking
• Reducing or eliminating alcohol use
• Sleeping on your side or stomach instead of your back

Most of these changes may not be directly covered as sleep apnea treatment. Some insurance plans offer reimbursements, discounts, or wellness benefits for certain expenses, such as nutrition counseling, gym memberships, and other preventive programs.

Tirzepatide (Zepbound) is a prescription medication originally approved for weight loss. It has since been approved for treating OSA in adults with obesity. Some health insurance plans, including Medicare, cover tirzepatide for the treatment of sleep apnea. Coverage often requires pre-authorization, so talk to your healthcare provider if you’re interested. They can help determine whether the medication is an option for you and assist with the approval process.

Understanding Out-of-Pocket Costs

Out-of-pocket costs are medical expenses that you’re responsible for paying. Health insurance plans typically cover 100 percent of preventive services, such as annual exams. Many other services are only partially covered. How much you pay depends on your policy and the type of care you receive. In some cases, you may be responsible for anywhere from 10 percent to 100 percent of the cost.

Common out-of-pocket expenses related to sleep apnea treatment may include:

• A copayment — A fixed amount you pay for a healthcare service or prescription
• A deductible — The amount you pay before insurance begins to cover certain services
• Coinsurance — The percentage you pay for a covered service after meeting your deductible

To keep out-of-pocket costs as low as possible and avoid unexpected medical bills, it’s important to understand your insurance policy. Be sure to know when prior authorization is required for equipment or procedures. You should also check which portion of the treatment you’ll be expected to pay.

Find out whether you need to provide documentation showing that CPAP machines and other devices are being used regularly to maintain coverage. Also, know your out-of-pocket maximum. Once you reach this limit, insurance typically covers 100 percent of your covered costs for the rest of the plan year.

Navigating insurance for sleep apnea can take time and patience, but understanding the basics can help you maximize your coverage while keeping costs affordable. Because rules vary by plan, it’s important to review your policy and talk with your healthcare provider and insurance company about your options.

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