Navigating CPAP Insurance Coverage: What You Need to Know
Posted by Remologie Staff
Everything you need to know about CPAP insurance coverage in Manitoba.
How has the CPAP provincial program changed?
Prior to April 23rd, 2018, the Provincial Program covered the full costs of CPAP treatment, including the initial machine, mask and other supplies, all service fees. Manitoba along with Ontario were the only provinces that provided any provincial funding.
Now, patients can purchase a machine for $500 once every 5 years; only if they’ve been diagnosed with sleep apnea through the Sleep Disorder Centre (received a prescription from the province). Patients are also responsible for the cost of ongoing supplies.
What is covered through the Sleep Disorder Centre’s provincial program?
- If you are diagnosed with Sleep Apnea, after being referred to the SDC Provincial Program by your family doctor, you will be offered a cost-free CPAP trial. You will receive a trial CPAP machine (rent-free), a mask and tubing to keep, and all the service and clinical appointments at no charge. *There is no cost to the patient to be on the SDC CPAP Trial.
- Following a successful SDC trial period, you can purchase a CPAP machine for $500 once every 5 years.
- Patients must cover all supplies after their CPAP trial. However, all service fees to see a clinical therapist continue to be covered by the provincial program.
- If you do a sleep study privately, you’re not eligible for any of the SDC provincial program benefits. However, if you complete a private sleep study through Remologie, you will not be charged for therapist appointments.
There are many variables when it comes to CPAP insurance: you (the patient), your insurance provider, your provincial benefits, and us (Remologie). It is our job to help you navigate through your CPAP treatment.
How does my private insurance provider fit in?
Every insurance provider and plan are different; therefore, how your provider fits into the equation will vary. However, through experience, we have picked up some information related to common insurance providers:
Canada Life (Great West Life)
- Canda Life is very particular about your claim form; they require us to submit the original document. Canada Life will not accept electronic forms (email/fax).
- If a patient wants a CPAP machine, Canada Life will require a separate form to be completed with the prescribing doctor’s signature (which may include a form fee from your doctor’s office).
- Most Canada Life plans cover the cost of resupply every 6 months for the mask, tubing, and chamber (Canada Life doesn’t pay for filters).
- Like Canada Life, GreenShield will require a separate form to be completed with the prescribing doctor’s signature (which may include a form fee) to cover the cost of a CPAP machine.
- In some cases, GreenShield will require you to prove the severity of your OSA in order to be eligible for the $500 co-pay (based on your sleep report).
- GreenShield also requires the sleep study report to come from the Sleep Disorder Centre. Therefore, you will have to ask the SDC for the report, as they don’t send this to us.
Pro Tip: If a CPAP claim has not been submitted to GreenSheild in 12 months, you will be required to submit a new prescription to access coverage. *Note: If you’re continuously replacing your supplies, they won’t question your eligibility
- Plans can vary greatly under Blue Cross but is a very efficient process.
- CPAP coverage is sometimes combined with Miscellaneous Medical, which can also be used for crutches, braces, wheelchairs, etc. This coverage is typically 80% up to $250 lifetime.
- Other plans we have seen are 80-100% up to $1000 annually, or 80% up to $2500 lifetime.
There are a few ways in which most insurance providers in Manitoba are the same:
- Almost no insurance providers cover private home sleep studies. They want the patient to go through the provincial program.
- Most insurance providers will only cover $500 for your CPAP machine even if you didn’t go through the provincial program and have paid privately. It is possible to appeal this for high-severity cases.
How does Remologie fit in?
Remologie will assist you in utilizing your insurance coverage.
We do not do direct billing to your insurance provider because there is no direct billing for respiratory products. Therefore, patients have two options:
- First, we recommend that patients pay upfront and then submit a claim to their insurance provider (if you have confirmed with your provider that you have insurance). This option has the fastest turnaround time.
- Second, in some cases, our partner Medigas Manitoba can support patients that can’t pay upfront through the “Assignment of Benefits.”
How does the “Assignment of Benefits” work?
The Assignment of Benefits allows you (the patient) to reduce/eliminate out-of-pocket costs. Through the Assignment of Benefits form, you allow Medigas Manitoba to collect payment from your insurance provider on your behalf. Once they’ve determined your coverage, you can receive your equipment and pay any outstanding balance above the prior approved amount. Medigas Manitoba will submit a signed claim form, a signed Assignment of Benefits form, your prescription, and an invoice. It is important to note that the patient is 100% responsible for any outstanding balance once the insurance payment has (or has not) been received. You will still be responsible to the provider for the entire cost.
Insurance companies that allow the Assignment of Benefits
- Canada Life (Used to be Great West Life)
- Manitoba Blue Cross
- Group Medical Services
- Johnston Group
- Sirius Benefits
- Chamber of Commerce
Insurance companies that won’t allow Assignment of Benefits:
- Claimsecure (Healthsource)
The Assignment of Benefits will need to be completed through our partner Medigas Manitoba. They only do insurance claims for orders over $200 and cannot bill accessories. Medigas Manitoba can only bill the CPAP necessities; mask, tubing, water chamber, CPAP machine, and filters if an add-on.
We still recommend that patients pay upfront and use their provider’s online portal to submit their claims; because it is easier and faster.
How do you (the patient) fit in?
The best way to get the most out of your insurance is to get in the know! It is important that you reach out to your insurance provider to find out if you have CPAP coverage. Here is a list of questions you should ask your service provider:
- Does my plan have CPAP coverage? If so, what is the coverage?
- Is there an annual or lifetime maximum for my CPAP coverage? If so, what is the balance of that maximum?
- What is my benefit frequency (i.e., how many masks could I get per year)? They only provide this information to the patient.
- Is there a maximum payable dollar amount per item?
Pro Tip: Many insurance plans allow for re-supply 2 times per year, including the mask, tubing, chamber and filters. Pricing must fall within reasonable and customary charges (at Remologie our pricing always falls below this amount).
- Do you require my initial sleep study that indicates the severity of my diagnosis? (Will mostly be applicable to GreenShield but it doesn’t hurt to ask).
- Does my plan allow for the Assignment of Benefits to the vendor? Note: Not all plans do, even with providers that sometimes allow for it.
- Does my plan cover the cost of the sleep study? Most won’t since we have a provincial program in Manitoba.
- Is there a deductible for my insurance?
If your insurance doesn’t cover your CPAP treatment; consider encouraging your workplace to improve its offering.
Our team frequently presents to Manitoba businesses in order to stress the importance of having good CPAP coverage in corporate plans. If you need help championing this issue, let us know!