CPAP from Vending Machines?
So you are looking for treatment for Sleep Apnea and want to find out the most important question, How much will it cost me? Well, you’ve come to the right place! We’ll go over the 3 routes to get a CPAP machine, Ministry Coverage and Insurance coverage and the difference between a Vendor and a Provider.
Looking for a provider with years of knowledge on CPAP insurance coverage and navigation overall reducing costs for all clients with extended health? Capital Home Medical is the only provider to successfully assist many patients recover money that is rightfully theirs!
3 Ways to Obtain a CPAP
1. Go through a readily available Private Sleep Study through Capital Home Medical Equipment and if clinically recommended, get set up on a CPAP Trial for 4 weeks with no wait time and get partial or full coverage for the CPAP package. Out of pocket expense for the CPAP package & sleep testing at the end of trial would be anywhere between $299.99-$1900.00. These machines are readily available and can have you treated within 1 week of testing. We are the only providers in Ottawa that have the expertise for insurance navigation which eliminates the headache for you in getting covered. Furthermore, many insurance companies need to see a CPAP failure in order to fund an Oral Appliance, which we would gather all necessary documents and refer to a renowned dentist with specialty in sleep.
2. Obtain a Prescription from your family physician:To purchase a new CPAP machine or Oral Appliance privately. This will be a 100% private pay with no assistance from the government or insurance for Ontario citizens.
3. Go through the Sleep Lab test: 6-12 month wait minimum for testing and then 3-4 months for treatment. This is the only way to get the Assistive Devices Program “75% coverage” (Coverage of $415.50). Although there is some coverage, the overall reduction in funding for CPAP machines in October 2021 has led to providers and vendors charging for any or all of the following:
Professional Service Fees
These Fees are not covered by insurance companies. Rental charges may be covered depending the insurer.
The ADP Application Form can be found here.
Please note: To TRY a CPAP machine, there is often a long wait time and costs anywhere from $300.00-$800.00 depending on the provider’s process. Further to that, rental fees are added on at an average of $200.00 per month. It is also worth noting that ADP-Funded CPAP machines are on backorder for months so it is very likely to be needing a rental for 3-5 months on average leading to a total rental cost of $600 - $1000 if you opt for government assistance. In the end, it will cost you more.
How much does The Ministry Of Health Cover for CPAP machines?
What does the Ministry of Health Cover for CPAP machines?
The Ministry of Health covers the dispensing of the CPAP machine, non-heated tubing and a “free mask”. That is all. Any reporting or human services will be tied to other service fees. Please take into consideration that the free masks are also on a backlog with no end in site.
The Ministry states they cover 75% of the cost of a CPAP. Has the Ministry of Health’s funding changed in the past years?
When reading this, keep this in mind and ask yourself: Have costs of raw items gotten higher? Has manufacturing costs gotten higher? Has fuel, and therefore shipping increased? Has human labor hourly wage gone up or down? How has COVID complicated the supply chain issue? How much are the CPAP machines being sold online with no service, paperwork handling or a place you can return the machine to and get a loaner in the event something happens?
Based on the table above, it is easy to see who is actually saving money. The Ministry of Health’s message with regards to the constant reduction in coverage is to “Save Ontarians money by subsidizing the costs of the CPAP machines”. What they have done is subsidize it to the point you should be getting the CPAP from a Vending Machine if you’d like a machine for $554.00. The problem that arises, is there will not be a human available or willing to monitor, send reports to the physicians, do the paperwork for billing the Ministry, chase physicians for signatures or provide any type of decent service for the CPAP machine as the reduction in funding strictly covers the bare bones of CPAP Therapy. So when factoring in service levels, keep this in mind as to what to expect.
The icing on the cake is that local, national and international companies are prioritizing sales and distribution of ADP-funded and Non-ADP-Funded machines to their online departments and to all other provinces rather than Ontario.
Since ADP funding does not exist in other provinces, there is no continuous reduction in coverage and therefore does not affect insurance coverage. For Example, in British Columbia, Quebec, Alberta and Saskatchewan CPAP machines have a retail price of $1900.00+ including services. This cost is completely or partially covered by private insurances as they deem the reasonable and customary cost to be up to $2300.00. In Ontario, for anyone with an OHIP card, insurance companies now deem $554.00 the reasonable and customary cost (whether or not going through ADP) due to provincial funding cuts and majority will only pay $138.50 for the CPAP package.
There was a point the Ministry covered the CPAP machine and services were able to be included and matched the rest of the provinces and other countries. This has ended due to the fiscal stimulus and increase in government debt and is now costing OHIP card holders more out of their own pockets to get treatment.
2 sides to every story: How, or better yet, WHO will provide services and products when they don't even break even with the new provincial funding for durable medical equipment. This will (already has) directly affect the service you get and quality of care.
End of day, Ontario citizens are now in a tough position where if they want CPAP therapy it will be extremely hard to find a machine and will cost much more than before. The only way around this would be to take it privately and find a company that can assist you with out of pocket expenditure by working with your insurance company, if applicable.
How does the Ministry reduction in coverage affect my insurance policy? How much will it cost me now?
As you may know, if you are an Ontario citizen and call your insurance, they will let you know you have coverage up to around $1500.00 - $2000.00 is the average. What they will omit is that you must apply for the Assistive Devices Program for the subsidized cost of the CPAP. This means, the $2000.00 dollars you were told has just been reduced to a MAXIMUM COVERAGE of $138.50 by your insurance for the purchase of the machine because they state you MUST go through a local ADP-Accredited provider and jump through all the hoops to get there without a care for the lengthy delays and your health. All other service or professional fee line items listed above that are added on are NON-INSURABLE EXPENSES, meaning it is all out of pocket to the consumer.
So let’s ask ourselves, does the Ministry of Health actually cover 75% of the cost as they advertise? The Ministry of Health has limited what ADP providers can sell the machine for but disregarded the sustainability of human labor yet expects there to be service for your CPAP needs. This has come down to literally handing the machine and a mask to the patient and saying, "good luck". This has also limited the amount Insurance companies pay out for the purchase of the CPAP machine alone to $138.50 and if a machine is obtained online or in any other way, they will either reject the claim in full or provide a partial payment of 138.50 as they have reduced their reasonable and customary cost to $554.00 for a CPAP machine, only in Ontario. If you go that route, there will also not be a way of obtaining the government financial assistance. Essentially they force all citizens that are looking for the 415.50 in coverage to wait 1-2 years for a sleep study through a sleep lab while you suffer with sleep deprivation and casue more harm to your health the longer you wait.
Having said this, if you live in any other province, there is excellent coverage through insurance companies since it is not regulated by a provincial Ministry of Health and therefore would have 80-100% of coverage for the entire CPAP package. Ontario still needs to catch up to the rest of the world with Home Sleep Testing that is readily available with treatment routes. However that is not likely going to happen any time soon since it is the province with the highest Sleep Labs per capita across North America and currently it states you MUST go through a sleep lab to be eligible for ADP funding in Ontario only.
Maybe it is time to place pressure on the insurance companies to override the system since sleep apnea is a known cause of many other comorbidities which requires medical intervention ASAP. Waiting 2 years for treatment can place your health and other's health in jeopardy and overall lead to a lower quality of life.
It's time for the premiums that you pay your private insurance to come before tax-payers money in order to be eligible for reimbursement and prioritize government funding for patients in financial need vs. everyone despite their income level.
Does your provider know the ins and outs of insurance coverage? This can heavily reduce your monetary burden!
Capital Home Medical Equipment is the only provider in Ottawa to have the expertise to manage insurance coverage and assist patients navigate their coverage.
For Additional articles regarding the cut in respiratory supplies coverage, check out this news release in 2021 when the changes were fresh: