How Does My Deductible Affect My CPAP Prices?

 In CPAP Insurance, Most Popular Posts

Deductibles and everything else in health insurance policies can be hard to understand and complex to say the least.  Deductibles, co-insurance rates, out-of-pocket maximums, in-network, out-of-network – a seemingly never-ending list… Well, Health Sqyre is here to help you figure out what all of these things mean so you can understand how to use your insurance to your advantage and save money when you’re buying your CPAP supplies!

To learn how deductibles affect your CPAP supplies purchases, we first need to review what a deductible is and how it works.  Ready?  Here we go…

What is a Deductible?

  • Deductible – the amount you must pay out-of-pocket in medical expenses before your co-insurance rate kicks in to lower the share of the cost that you pay for medical expenses (CPAP supplies in this case).
  • Deductible Met – the amount you have paid out-of-pocket in medical expenses that is counted toward your overall deductible.
  • Deductible Remaining – the amount that you have remaining before you have completely met your deductible.

Note: Deductible = Deductible Met + Deductible Remaining

What are Common Deductible Amounts?

  • There are different deductibles for different health insurance plans that range from $0 deductibles, or no deductible, all the way up to $6,500 (if not higher) deductibles.
    • Here are two examples of possible health plan deductibles:
      • High Deductible – $6,500
      • Low Deductible – $1,000

Pro Tip:  A plan with a higher deductible usually results in a lower monthly premium cost – these plans are often referred to as “Catastrophic Plans.”  On the other hand, a plan with a lower deductible usually has a higher monthly premium cost.

Did you know?: Most health insurance plans reset the amount of the deductible that has been met to $0 on January 1st of each year.

This means that it if you have met your deductible or are close to meeting your deductible near the end of the year, say around October, November, or December that you should be buying your CPAP supplies…  Why?  Because you’ll only have to pay your [co-insurance rate] instead of the full amount!

How Does My Deductible Affect My CPAP Supplies’ Cost?

Long story short, it affects the amount you pay out-of-pocket and how much your insurance will pay.  We will walk through three specific examples to will make it clearer.  But first, is the CPAP product you want to buy covered by insurance in the first place?

Is the CPAP Product You Are Buying Covered by Insurance?

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Most machines, masks, humidifiers, tubes, and filters are covered by insurance – yay!!! However, some supplies like CPAP cleaning supplies (ex: [SoClean]) and travel CPAP’s are not covered by insurance. (Here is a list of CPAP supplies that are not covered by insurance.)  Health Sqyre has put together a list of each type of CPAP supply along with its associated HCPCS code so that you can see which [CPAP supplies are covered by insurance] and how frequently your insurance will cover each CPAP supply.

If you have more questions, please check out Health Sqyre’s Comprehensive List of Insurance Eligible Products.  We also have a list detailing CPAP Items Not Covered by Insurance, in case you are more interested in that!

How Much of Your Deductible Have You Met?

The amount of your health plan’s deductible that you have met (amount you have spent out-of-pocket on medical supplies) will be somewhere in the following three categories: Zero Deductible Met, Deductible Partially Met, or Deductible Met.

We are going to use King Arthur, yes he was a former sqyre, for our examples below.  Here is what we need to know about Arthur and his insurance plan:

Patient Information

Deductible Information Patient

Name: King Arthur

Insurance Provider: Aetna

Deductible (In-Network): $3,000

Co-Insurance Rate (In-Network): 20%

Product Overview

resmed-airsense-10-cpap

Product: ResMed AirSense 10 AutoSet CPAP with HumidAir Humidifier

Manufacturer: ResMed

HCPCS Code(s): E0601, E0562, A9279, A7037

Price: $883

Note: This example assumes that (1.) Arthur has not met his [Out-of-Pocket Maximum] and (2.) that Arthur is using his insurance to purchase CPAP supplies from an [In-Network] store.

In this example, Arthur has spent all $3,000 out-of-pocket of his deductible on medical supplies/services. This means that Arthur has met his deductible, and insurance will start sharing the cost with him through his co-insurance rate.

Zero Deductible Met – Arthur’s Deductible Met is $0

Arthur’s Insurance Status Before Purchasing a CPAP Machine

Deductible: $3,000

Deductible Met: $0

Deductible Remaining: $3,000

Price of Product: $883

Amount Arthur Pays (Out-of-Pocket): $883

Amount Arthur’s Insurance (Aetna) Pays: $0

Arthur’s Insurance Status After Purchasing a CPAP Machine

Deductible: $3,000

Deductible Met: $883

Deductible Remaining: $2,117

Pro Tip: If it is cheaper for you to pay in cash and not use your insurance [Health Sqyre will submit a claim to your health insurance company for FREE.] This will allow the purchase to count towards your deductible most of the time!

Pro Tip: Cash prices are typically cheaper than insurance prices, so if you have not met your deductible it’s usually cheaper to pay for your CPAP supplies using cash (out-of-pocket) instead of using your insurance.

The cost of the CPAP machine that Arthur purchased has been added to Arthur’s deductible met.  Seen a different way, Arthur’s deductible remaining has now decreased by the same amount – $883 and is now only $2,117.

Deductible Partially Met – Arthur’s Deductible Met is $2,500

In this example, Arthur has spent $2,500 out-of-pocket on medical supplies/services.  This means that Arthur has to spend $500 more out-of-pocket on medical supplies/services before his insurance will start sharing the cost with him through his co-insurance rate.

Arthur’s Insurance Status Before Purchasing a CPAP Machine

Deductible: $3,000

Deductible Met: $2,500

Deductible Remaining: $500

Price of Product: $883

Amount Arthur Pays (Out-of-Pocket):

  • Out-of-pocket amount needed to meet his deductible: $500
  • Co-insurance Amount (20%): $883-$500 = $383*20% = $76.60
  • Total: $500 + $76.60 = $576.60

Amount Arthur’s Insurance (Aetna) Pays:

  • Co-insurance Amount (80%): $883-$500 = $383*80% = $306.40
  • Total: $306.40

Under these circumstances, Arthur will pay a total of $576.60 out-of-pocket because he has not met his deductible yet.  Arthur is required to pay $500 out of pocket to meet his deductible.  The amount the product costs over $500 is then shared with his insurance company through his co-insurance rate.  In this case, the shared amount is $383 ($883-$500).  He owes his portion of the co-insurance rate, 20% on this amount, which comes to $76.60 ($383*20%).  His insurance will then pay for their share of the co-insurance rate, 80% on this amount, which comes to $306.40 ($383*80%).

Arthur’s Insurance Status After Purchasing a CPAP Machine

Deductible: $3,000

Deductible Met: $3,000

Deductible Remaining: $3,000

For any of Arthur’s future medical supply/services purchases, he will only be responsible for his co-insurance rate portion.  Once he has [met his out-of-pocket maximum] then he won’t be responsible for any of his share and his insurance company will be responsible for covering 100% of his medical purchases.

The cost of the CPAP machine that Arthur purchased has been added to Arthur’s deductible met and he has now completely met his deductible.  Seen a different way, Arthur’s deductible remaining has now decreased to zero.

Deductible Met – Arthur’s Deductible Met is $3,000

In this example, Arthur has spent $0 out-of-pocket on medical supplies/services.  This means that Arthur has to spend $3,000 out-of-pocket on medical supplies/services before his insurance will start sharing the cost with him through his co-insurance rate.

Arthur’s Insurance Status Before Purchasing a CPAP Machine

Deductible: $3,000

Deductible Met: $3,000

Deductible Remaining: $3,000

Price of Product: $883

Amount Arthur Pays (Out-of-Pocket ):

  • Out-of-pocket amount needed to meet his deductible: $0
  • Co-insurance Amount (20%): $883-$0 = $883*20% = $176.60
  • Total: $176.60

Amount Arthur’s Insurance (Aetna) Pays:

  • Co-insurance Amount (80%): $883-$0 = $883*80% = $706.40
  • Total: $706.40

Now, Arthur will only pay his share of the co-insurance rate (20%) out-of-pocket because he has met his deductible.  This means that his out-of-pocket cost is $176.60 ($883*20%).  Alternatively, his insurance will pay their share (80%) of the CPAP machine, which totals $706.40 ($883*20%).

Arthur’s Insurance Status After Purchasing a CPAP Machine

Deductible: $3,000

Deductible Met: $3,000

Deductible Remaining: $3,000

The cost of the CPAP machine that Arthur paid out-of-pocket through his co-insurance rate did not affect his deductible met because it has already been met (fully paid).  However, the money that Arthur did spend paying the co-insurance rate will go toward his out-of-pocket maximum amount.

Pro Tip: Know how close you are to meeting your annual out-of-pocket maximum, as this could save you lot of money. If you have met your out-of-pocket maximum then your insurance company will pay the entire cost for the CPAP supplies that you need according to the reimbursement schedule!

Deductibles are the first components in the insurance equation.  The next are co-insurance rates and out-of-pocket maximums.  To learn about how those work and how they affect the cost of your CPAP supplies simply click on those links.

Deductibles can be tricky.  Fortunately for you, [Health Sqyre can get your insurance information (all of it – deductibles, co-insurance rates, out-of-pocket maximums) for FREE in real-time] and tell you what CPAP supplies are covered by your insurance.

Real Examples of How Deductibles Work

If you would like to see real world examples of insurance plans with a high deductible, deductible met, or family deductible met, please visits our Patient Case Studies Page!

Health Sqyre can get your insurance policy coverage information for FREE in real-time and tell you what exactly what CPAP supplies are covered by your insurance (and what the cost out-of-pocket) is to you.

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