How to buy (and/or get insurance to pay for) a CPAP machine
November 20, 2015 8:03 AM   Subscribe

I've been using a CPAP machine for a long time, and my current machine is dying quickly. How can I pick a new machine, and what is the best way to do this through insurance?

I've been using a CPAP machine for almost 10 years, and the bearings in the machine I have been using the entire time are finally giving up the ghost. I have an appointment with my original doctor next week, and will hopefully get a prescription for a new machine.

When I originally got the machine, my doctor's office took care of the entire process, contacting a Durable Medical Equipment supplier, who then brought the machine to my house and instructed me on how to use it. The problem is that I really had no choice in machine or supplier, and the rent-to-own process was entirely opaque. (Pay the monthly bill until you stop getting monthly bills. No idea how much the machine really cost)

There has to be a better way to do this. Should I just bite the bullet and buy from an online source? None of those seem to handle insurance claims, so they would be out-of-network for me. How do you evaluate medical equipment companies? Will any of them give you a choice of machine, or just the one that makes them the most money?

Medical issues seem to be one of the few places in the US where you're expected to consume without any idea of true costs up front.
posted by dforemsky to Health & Fitness (11 answers total) 9 users marked this as a favorite
Call your insurance to find out what your cost will be for a new machine. The code for a CPAP is E0601. That'll help them give you a better idea about your cost responsibility. Ask them which DME companies they are contracted with as that will get you the best coverage. Research them if you want but where I live they are mostly all the same.

What kind of machine you get depends on the prescription written. As a sleep PA I always prefer Respironics units (System One or the newest Dream Station) because the data I get from them is the most robust and provides the most benefit to me in a clinical context. Resmed units are pretty good as well. There are lots others but I have little to no experience with these machines. Basically if your doctor does not write for a specific machine DME places may give you whatever the heck they want if they are billing your insurance.

If you decide to pay out of pocket online I would look into the System One 60 series because Respironics just released a new model the prices are lower on the older model. Maybe, 500 dollars? My experience has been that patients who buy online get sent to them a machine not set at their prescribed pressures. So best to bring it in to your physician to have it set correctly.
posted by teamnap at 8:18 AM on November 20, 2015 [4 favorites]

I gotta be honest, it was such a labyrinthine rigmarole dealing with the insurance that I said screw it and paid out of pocket for mine.

If you do end up paying out of pocket you can save a few hundred bucks by buying a very gently used machine from Secondwind CPAP. I highly recommend them (a LOT of their machines have less than 100 hrs of use). Or, if you'd prefer a new machine, I highly recommend As a bonus, if you don't go through insurance you don't have to meet the usage requirements that mandate that you rent the machine for a certain number of months before buying it. I just found it to be a ridiculous ordeal.

Whatever you do, educate yourself on the machines before you deal with any DME. The DME is a salesperson, not an expert on the machines, and they will likely steer you to any unit that makes them the most money. The most popular and best selling machine on the market is the ResMed AirSense 10 AutoSet, but Philips Respironics just came out with their newest model, the DreamStation. I personally chose a Fisher & Paykel ICON Auto and couldn't be more pleased. Make sure to get a heated hose with whatever unit you choose -- it makes all the difference!
posted by lock sock and barrel at 8:23 AM on November 20, 2015 [1 favorite]

If your insurance covers it, chances are they will want you to start all over with a specialist's evaluation and prescription etc. That's what my wife needed to do when she got a new one recently. The new machines have chips that essentially put you through a sleep study in your own bed; you send the chip to the doctor so the machine can be correctly calibrated for you. Yes, there's a bit of rigmarole, but it's probably worth going through in order to have the right setup.
posted by beagle at 8:25 AM on November 20, 2015

By the way, if you buy online you can tell the supplier to set your machine to the pressure you want it set to. But you can always access the clinician's menu on any machine to set it yourself, just check out the instructions here or here.
posted by lock sock and barrel at 8:28 AM on November 20, 2015

A sleep study is a separate issue than the machine. You need to visit your doctor first, and determine if you need a new sleep study, or if the pressure you've been using is providing you with effective therapy. Once the doctor determines what pressure you need is when the buying of the machine comes into play.

The new machines (APAP) don't put you through a sleep study, but they're designed with an algorithm that automatically senses your breathing patterns during the night and adjusts the pressure accordingly. So instead of a fixed pressure as with the regular CPAP, the APAP fluctuates. This can work really well for some people, and yet others do better at the fixed pressure.

Check out CPAPtalk or ApneaBoard for a lot of useful guidance.
posted by lock sock and barrel at 8:40 AM on November 20, 2015

You can try craigslist, but be sure to check how many run hours it has on it. I'd also stop in at a DME and ask them to test that it's blowing the actual pressure you set it to.

Another useful resource - both for the forums and the store:
posted by dancing leaves at 8:44 AM on November 20, 2015

Just to note, secondwindcpap also sells new machines. My mother bought two new machines from them, because despite their old school website, they have great prices and are very easy to deal with.

She had a Respironics from the DME, but even with insurance and after 3 months rent pro-rated, it still would have cost her about $800 to buy it. Insurance retail for machines from DMEs runs around $2000.00. That's why she bought a new machine direct for about $550. She didn't like that machine (DeVilbiss Intellipap) as well, so she recently bought a new Respironics of the same model as before when the new model came out and the price dropped. The Respironics machine has a better brain and integrated heated tubing. The DeVilbiss is now her travel machine.

LS&B is right. Get the heated tubing. Best upgrade.
posted by monopas at 8:45 AM on November 20, 2015

The new machines have chips that essentially put you through a sleep study in your own bed; you send the chip to the doctor so the machine can be correctly calibrated for you.
Mine is a ResMed and the technician set it up before I picked it up and it calls in the data each day. It is literally a cellular phone call from the machine each day with no need for me to do anything. There is a chip to store data in case of communication failure.

Ten years have passed and your doctor's office may do things differently now. If they don't, ask them about the different machines and how to pick one. Someone in their office should be able to help you with the insurance part including telling you the costs upfront. My office told me the price and said my insurance would decide between renting and buying the machine. They will buy most of the other parts that need frequent replacing. If they are cagey about questions, think about a different doctor.

None of those seem to handle insurance claims, so they would be out-of-network for me.
You might be able to buy one and then submit a claim to your insurance company. Call them and ask. Just because the supplier doesn't handle the claim does not mean they are out of network. My insurer's website lets me search for providers.
posted by soelo at 9:36 AM on November 20, 2015

Perhaps this is obvious, but if your employer has a Flexible Spending Account plan that allows you to set aside pre-tax earnings to pay for medical expenses, a lot of plans are currently in the time window where election changes are permitted for the coming year. If you think you can get your current machine to last through the remainder of this year and have not maxed out your contribution to any FSA plan you are eligible for, change your plan contribution level now so you can pay with pre-tax dollars. (Or, if you have remaining dollars from this year's contribution, don't forget to use them.)
posted by Nerd of the North at 9:59 AM on November 20, 2015

I haven't yet used my insurance to pay for my CPAP machine and supplies because of weird timing issues (changed jobs after my initial sleep study but before the bill for my CPAP arrived), so I've paid for my gear out of pocket.

I'd like to second lock sock and barrel above. I bought 2 CPAPs from Second Wind CPAP (previous ask about CPAPs) and they are both going strong to this day.
posted by Rob Rockets at 10:40 AM on November 20, 2015

Adding my two cents...

In addition to the APAP/CPAP machines changing in the last 10 years, so have the masks. The good news it that the tubing is generally a standard size so you can use any mask with any machine. There are some exceptions. I use the Respironics System One with heated tubing and humidifier. I use a ResMed Airfit mask. I can't use the nasal pillows because I breathe through my mouth. I like that the AirFit does not have anything on my forehead.

The CPAP forums are helpful and have a lot of information about different machines and masks, along with members' experiences with various suppliers. Also, one of the forums has a link to software that reads the SD card from your machine, so you can monitor the effectiveness of your therapy yourself.

There are some horror stories out there about various DME suppliers. The one I used with my insurance company did fit my mask well, but they gave me the standard headgear which is too big. I ordered the small headgear and it fits much better.

What I didn't like about the DME is that they would not just tell me the price up front, but I had to sign a contract with a lot of conditions. I returned the machine from the DME before the compliance period expired because my deductible had just kicked in again and I was unemployed, and ordered a new one from secondwind CPAP.

I still don't understand how they can require people to sign a contract that doesn't specifically state the amount I would be responsible for given the specified conditions, but needed the machine.
posted by Altomentis at 6:40 PM on November 20, 2015

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