How does my insurance work? What’s a copay, co-insurance and deductible?
Copay: The amount that you are responsible for paying yourself, as mandated by your insurance contract, to have a sleep study or other services.
Deductible: This is the total amount that the patient needs to pay initially out of pocket before the insurance company makes any payments for medical services. For instance, if your insurance plan has a $1000 deductible per year, you have to pay this amount in full before your insurance company starts to contribute.
Co-insurance: Some insurances have a co-insurance instead of/in addition to a deductible. This means that the patient is responsible for a percentage of the fees of the medical services. For instance, if your insurance plan has a 20% co-insurance, this means that your insurance will make you responsible for 20% of the fees and they will pay the rest. This is usually after the deductible has been met.
Out-of-pocket Maximum: The most you’ll have to pay during a policy period (usually a year) for services. Once you’ve reached your out-of-pocket max, your plan begins to pay 100% of the allowed amount for covered services.
Will my insurance cover my sleep study or PAP device?
Most insurances (HMO, PPO and Medicare) cover sleep studies and PAP therapy for the treatment of sleep disorders. Plans may vary in their coverage (see below: rental versus purchase for PAP device set-ups and in-lab denied for in-home sleep testing) and many now require authorization for these services. These authorizations can take your insurance company up to 21 days to process.
Will I have a copay?
Based on your insurance coverage, you may have a copay for your sleep study, PAP device set-up or replacement supply order. If this is the case, we will let you know at the time of service (for supply orders we will send you a statement once we receive the explanation of benefits after your claim is processed by your insurance company) and collect your payment.
Will my insurance company require authorization for my sleep study or PAP device?
Many insurance companies, including PPO and commercial plans, are now requiring authorizations for more and more services, including sleep studies and PAP devices. As a courtesy, we will request authorization from your insurance company and sometimes authorizations are denied or more information is required from the patient or physician. If this is the case, we will contact you to help us provide the information requested to your insurance company. Some insurance companies can take up to 21 days to authorize services, so please be patient with us.
Why did my insurance company deny my in-lab study and approve home sleep testing?
Some insurance companies are now requesting in-home studies (HST) rather than in-lab testing . Typically, they will deny a request for in-center testing if there are no significant medical issues.
Will my insurance pay for the purchase or monthly rental of my PAP device?
Many insurance companies are now paying for PAP devices on a monthly basis as a rental. You may call us at 866-987-1611 or email us at info@americansleepcenters to find out if your insurance will be paying as a rental or purchase. You are also welcome to call your insurance company to find out all the details directly.
Why is compliance required for my PAP device rental?
Many insurance companies now pay for PAP devices on a monthly rental basis, typically 4 to 10 months. At the end of this approved rental period, you will own the device. Because it is a monthly rental, your insurance may require a monthly or quarterly compliance report to continue payment for the device.
A compliance report is proof that you are using your device for a minimum of 4 hours per day at least 22 days out of a consecutive 30 day period within the preceding 90 days (in the past 3 months).