Does Health Insurance Cover Sleep Disorders?

Generally, yes. Health insurance does cover sleep disorders, sleep studies and sleep disorder treatments.

Depending on the type of health insurance you have, you may need to pay a deductible for sleep studies and treatments. And if you have Medicare, your primary physician must refer you to a sleep clinic with a statement that your sleep study is medically necessary.

This article aims to answer all your questions about sleep disorders and health insurance in an unbiased way. It covers the following points:

• What are common sleep disorders?
• Does health insurance cover these sleep disorders?
• What is a sleep study? Is it covered by health insurance?
• What to expect during a sleep study
• The costs of sleep studies and sleep disorder treatments with and without health insurance
• Medications for sleep disorders and health insurance
• Which type of health insurance is best for individuals with sleep disorders?
• Does health insurance cover replacement CPAP machines?
• About insomnia and insurance
• Key takeaways

Let’s begin with a look at common sleep disorders.

What Are the Most Common Sleep Disorders?

Everyone has trouble sleeping from time to time. Sometimes, sleep disorders can be solved with lifestyle changes, like decreasing your caffeine intake, getting plenty of exercise and reducing your stress levels.

But if your sleep issues are causing major health problems, or making it difficult to attend to daily tasks, you may need medical aid.

According to the US Centers for Disease Control and Prevention (CDC), key sleep disorders include:

• Insomnia: difficulty falling asleep or staying asleep
• Narcolepsy: excessive daytime sleepiness, including episodes of irresistible sleepiness during the day
• Restless leg syndrome (RLS): an unpleasant “creeping” sensation in your legs that occurs when you try to sleep
• Sleep apnea: a disorder that momentarily disrupts sleep, and may be associated with gasping, snorting and snoring

Does Health Insurance Cover These Common Sleep Disorders?

Many sleep disorder treatments will be covered by health insurance. But your physician will need to speak with you and may suggest a variety of treatments.

Sleep disorders — and especially sleep apnea — can affect your quality of life and overall health. Your best bet is to call your health insurance provider to see exactly what is covered by your plan. Then, visit your primary physician to discuss your concern about a sleep disorder.

To treat insomnia, your doctor might suggest dietary supplements including melatonin or magnesium. Generally, these are over the counter (OTC) products, not always covered by health insurance.

If your doctor suspects that you suffer from sleep apnea, they will likely order a sleep study, to be completed overnight at a sleep clinic. Following that, you may need a continuous positive airway pressure (CPAP) machine. These are also usually covered by health insurance.

What is a Sleep Study? Is it Covered by Health Insurance?

Sleep studies usually take place at a sleep clinic. According to John’s Hopkins Medicine, “The most widely used type of sleep study is a polysomnogram.” You will sleep in a state-of-the-art lab that feels like a cozy hotel room. A technician in a nearby room records your brain activity and other data from your body.

Armed with all that data, the sleep clinicians can create a detailed report of your sleep patterns. They’ll learn:

• How much time you spend in light and deep stages of sleep
• If you’re getting enough oxygen while you sleep
• How often you wake
• And whether your sleep is disturbed by arm and leg movements

Individuals living in rural locations may need to travel into a major city to have a sleep study, and they are expensive. According to one sleep specialist, one sleep study should cost around $1,000. And a CPAP machine, if prescribed for sleep apnea, will also cost about $1,000.

Your next question is, “Are sleep studies covered by insurance?”

Yes. Generally, sleep studies, treatment and medical devices for sleep disorders (CPAP machines) are covered by insurance. If your insurance policy is an HMO, choose an “in-network” provider who works with your insurance company.

What to Expect During a Sleep Study

Most patients arrive at the sleep center in the evening. After checking in and completing some paperwork, you’ll head into a cozy room that feels like a nice, clean hotel room. You’ll see a bed and some medical devices.

There, a technician will apply small sensors to your body and head using a sticky adhesive. The wires will be gathered above your head with plenty of slack, so they won’t be pulled away as you sleep.

If your physician thinks you are coping with sleep apnea, you may also be fitted for a CPAP machine at this time. Most patients find this a bit unusual and uncomfortable at first. But the results are worth it!

Then, they might wrap elastic belts around your chest to measure your breathing during the night, and a clip might be placed on your finger or earlobe to monitor your oxygen levels.

While you may feel a bit unusual about all this equipment, it’s not terribly uncomfortable. Most people get used to it quickly and can fall asleep without much trouble.

If your sleep technician suspects that you’re living with obstructive sleep apnea, they may set you up with a CPAP machine during the night to see if your symptoms improve.

After the Sleep Study

It may take a few weeks for the results to be analyzed and reported to your physician. From there, your doctor can decide which treatments may be best for your unique needs.

They may prescribe a CPAP machine, diet and lifestyle changes, sleep aid medication, or something else. It really depends on your sleep disorder and other health issues.

Know that CPAP machines are generally covered by insurance, but you may need to pay a hefty deductible, depending on your insurance policy (and then again, maybe not.) We’ll take a closer look at those details shortly.

The Costs of Sleep Disorder Treatments, With and Without Health Insurance

Medical care in the US is expensive, that’s why most people appreciate health insurance. Still, the costs of testing and treatments for sleep disorders will vary greatly all around the US, and even from one community to the next.

The type of health insurance you have — we’re talking about the metal tiers, bronze, silver, gold or platinum — will affect your out-of-pocket costs as well.

So, using our average of $1,000 for a sleep study and $1,000 for a CPAP machine, let’s imagine your possible costs.

Of course, these numbers are only an average, and fabricated to illustrate possible expenses. Your actual costs for sleep studies, doctor visits, CPAP machines and so on will vary.

Plus, if you’ve already met your deductible for the year, you may not need to pay for your sleep study.

Medication for Sleep Disorders and Insurance

Depending on the sleep disorder you’re living with, your doctor may prescribe sleep aid medication. Many of these medications are covered by your health insurance plan. Your cost will depend on which type of insurance you have, and the price your insurer agreed to pay.

Common Medications for Sleep Disorders

Common medications for sleep disorders include:

• Daridorexant
• Doxepin
• Lunesta
• Dayvigo
• Ramelteon
• Zaleplon
• And many others

Health insurance companies have a drug plan called a formulary that describes the medications they cover. Sometimes, your doctor can convince them to cover a specific drug by explaining that it’s medically necessary. Other times, your insurance may cover a generic version of a drug, but not a name brand.

If you’re shopping for health insurance, and you have a regular prescription for a sleep aid, be sure to discuss this with your insurance agent. They’ll help you find a plan that covers your preferred medication at a cost that makes sense.

Which Type of Health Insurance is Best for Individuals with Sleeping Disorders?

There is no simple answer to this question. Your choice in health insurance should consider your budget, your known health situation, and your concerns for the future.

At first glance, the most affordable health insurance plans are in the Bronze tier. You’ll pay a lower monthly premium, but you’ll pay higher deductibles and pay more for your prescriptions. It may make sense to purchase a more expensive plan, with a higher monthly premium, because you will spend less on medications every month. Again, this is something to discuss with the health insurance agent.

Does Health Insurance Cover Replacement CPAP Machines or Parts?

Usually, yes. Most health insurance plans will cover at least part of the cost of a replacement CPAP machine. Some of the consumable/replacement parts, like plastic tubing, will be your responsibility. But there’s more to think about, because insurance companies can base their coverage for replacement CPAP machines on the severity of your diagnosis.

Insurers Base Coverage for Replacement CPAP Machines on the Severity of Your Sleep Disorder

According to Sleepfoundation.org, insurance companies will consider your apnea hypopnea index (AHI) when determining your eligibility for CPAP therapy. Your AHI is the average number of partial or complete breathing cessation events you experience in an hour. That AHI number is discovered during your sleep study.

Sleep apnea is classified as mild, moderate or severe, based on your AHI number. For instance:

• An AHI between 5-15 is classified as mild
• An AHI of 15-30 is moderate
• An AHI above 30 is severe

Now, Medicaid and Medicare will partially cover CPAP machines for all three AHI indexes, but other insurance companies have different standards. You may only be allowed one replacement CPAP machine every three years, or one new machine every five years.

Most CPAP machines are designed to last 3 to 5 years. Therefore, it makes sense to talk to your health insurance company about replacement requirements. Otherwise, you may find yourself paying for a new CPAP machine out-of-pocket when the time comes.

Awareness of sleep apnea is increasing, which means more insurance companies are ready to help you pay for the costs of this sleep disorder.

Other common sleep disorders are usually covered by health insurance. The most common one is insomnia.

About Insomnia and Insurance

Occasional insomnia is not covered by health insurance. This is something most of us endure in our lives, and it doesn’t affect our overall health or ability to handle daily tasks of living, like cooking a meal or making it to the bathroom on time.

Still, insomnia can become dangerous. Per CDC, insomnia can manifest as difficulty falling asleep, or as early morning awakening. Either way, insomnia becomes an issue when the patient experiences functional impairment throughout the day.

If you are suffering from insomnia, you should visit a doctor. This will be treated and billed like any other standard doctor visit through insurance. In other words, you will pay the usual co-pay required by your plan.

During your appointment, your doctor will rule out possible causes for insomnia (like depression, substance misuse, stress, or other illnesses.)

Ultimately, your doctor may treat your primary insomnia with medications and lifestyle changes. Most of these prescriptions are covered by your health insurance. If not, your doctor may be able to call the insurer and get coverage on your behalf, by describing it as medically necessary.

Health Insurance and Sleep Disorders: Key Takeaways

Ultimately, most of the costs associated with a genuine sleep disorder will be covered by health insurance. Your health insurance will offer some financial assistance for things like:

• Doctor appointments
• Referrals to sleep specialists
• Sleep studies and sleep clinics
• CPAP machines and some replacement parts
• Prescription medications

If you suspect you’re living with any kind of sleep disorder, call your physician today. The sooner you can have this issue sorted out, the sooner you’ll feel better every day. The entire process might take several weeks, but the results are worth it.