So you are looking for treatment for Sleep Apnea and want to find out one of the most important questions, 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 specifically in Ontario, Ministry Coverage, and the effects of ADP (Assistive Devices Program) on Private Insurance coverage and we will touch on some of the history of funding.
At Capital Home Medical we provide transparent advice without the fine print.
3 Ways to Obtain a CPAP
01.
Private Sleep Study
- No Wait Times
- Insurance Navigation
- Similar Costs to Public Funding Routes
1 week Turnaround time for Interpreted Sleep Test Results
- Multiple Sleep Solution Therapies Review
02.
Prescription from your family physician
To purchase a new CPAP machine or Oral Appliance privately. This will be 100% private pay with no assistance from the government or insurance for Ontario citizens. Many physicians will ask for a sleep test prior to signing a CPAP prescription.
03.
Public Funded Sleep Lab test
- Similar Costs to Private Routes of Sleep Therapy
- 6-12 month wait times
- Service Fees not covered by insurance
- $415.50 Provincial coverage towards CPAP Therapy
Home Sleep Testing (Private):
$300.00 Immediately Available
CPAP Monitor and reporting by
RRT if Clinically indicated
CPAP Therapy Total cost:
$1750.00
Ministry Funding for CPAP:
$0.00
Capital Home Medical Therapy Rebate:
$250
Total CPAP Package before
insurance coverage: $1500.00
*Insurance Coverage (If Applicable):
$325 - $1350.00
Sleep Lab Testing (Publicly Funded)
FREE - 6 month- 1 year Wait
CPAP Monitor and reporting by
RRT if Clinically indicated
CPAP Therapy Total cost:
$1750.00
Ministry Funding for CPAP:
$415.50
Capital Home Medical Therapy Rebate:
$0.00
Total CPAP Package before
insurance coverage: $1334.50
Insurance Coverage (If Applicable):
$325 - $1350.00
All CPAP Packages from Capital Home Medical Equipment come with 5 year worry-Free Therapy:
Monitoring & Titration, RRT backed therapy, warranty, and rental equipment if needed.
Costs and services may vary from different providers
Frequently Asked Questions
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”. 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 sight.
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 the costs of raw items gotten higher? Have 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?
Year | Subsidized CPAP Price | Coverage Amount (75%) | Patient Amount (25%) |
|---|---|---|---|
2015 | $ 2160.00 | $ 1620.00 | $ 540.00 + CPAP Mask + heated Tubing |
2016 | $ 1860.00 | $ 1395.00 | $ 465.00 + CPAP Mask + heated Tubing |
2017 | $ 1560.00 | $ 1170.00 | $ 390.00 + CPAP Mask + heated Tubing + Protection Package |
2019 | $ 86000 | $ 645.00 | $ 215.00 + Fees + Protection Package + CPAP Mask + Heated Tubing |
2021 | $ 554.00 | $ 415.00 | $ 138.50 + Protection Package + Surcharges + CPAP Accessories |
The Ministry of Health’s message with regard to the constant reduction in coverage is to “Save Ontarians money by subsidizing the costs of the CPAP machines and make it affordable”. 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, perform 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.
Why?
Since ADP funding does not exist in other provinces (Other than Manitoba and Saskatchewan), there is no continuous reduction in coverage and therefore does not affect insurance coverage.
For Example, in British Columbia, Quebec, and Alberta, CPAP machines have a retail price of $1700.00+ including services. This cost is completely or partially covered by private insurance as they deem the reasonable and customary cost to be up to an average of $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 will only pay $138.50 for the initial CPAP package. The remainder of the price is service fees, rental, and accessories.
In Manitoba and Saskatchewan, the Ministry covers substantially more CPAP therapy (Higher subsidized cost) as they also cover the services that are tied into therapy. This allows providers in these provinces to not have to charge rental or professional fees.
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: The reduction in the cost of CPAP therapy IS a good idea as that makes it more obtainable by the general population. However, when there is an inefficient, vague, unchanged, or updated system with current technology for over 15 years, it makes the process nearly impossible for those in financial need requiring therapy.
Unfortunately, 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 best 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?
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 unless there is clarification on your current residence. The agents generally omit 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 for the purchase of the machine. 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.
Does the Ministry of Health actually cover 75% of the cost as they state? 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". Furthermore, it has 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.
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.
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