We Handle Your Insurance
Navigating insurance coverage can be confusing. That's why we take care of the entire process for you—from verification to claims submission.
Our commitment: You'll know your estimated out-of-pocket costs before treatment begins.
Insurance Coverage Overview
Sleep apnea is a recognized medical condition, and both testing and treatment are typically covered by medical insurance (not dental insurance). The good news: most insurance plans, including Medicare, provide substantial coverage for both home sleep testing and oral appliance therapy.
Sleep Testing
Home sleep apnea tests are widely covered by medical insurance when medically necessary.
Oral Appliances
Custom oral appliances for diagnosed sleep apnea typically covered at 50-80% after deductible.
Follow-Up Care
Ongoing monitoring, adjustments, and follow-up testing generally covered as part of treatment.
What's Typically Covered
Diagnostic Testing
- Home Sleep Apnea Test (HSAT)
- In-lab sleep study (polysomnography) when medically necessary
- Sleep physician interpretation and diagnosis
- Follow-up sleep study to verify treatment effectiveness
Oral Appliance Therapy
- Initial consultation and evaluation
- Custom oral appliance fabrication
- Delivery and fitting appointments
- Adjustment and titration visits
- Routine follow-up care and monitoring
- Appliance repairs (if covered by warranty)
- Appliance replacement (typically every 3-5 years)
Medicare Coverage
Medicare Part B Covers Oral Appliances
Medicare beneficiaries have coverage for oral appliance therapy under Medicare Part B (medical insurance), not Part A or dental plans.
Coverage Requirements
Medicare will cover oral appliance therapy when ALL of the following criteria are met:
- 1Diagnosed OSA: You have a diagnosis of obstructive sleep apnea confirmed by a qualifying sleep study (in-lab or HSAT).
- 2Physician order: A physician (MD or DO) prescribes the oral appliance as medically necessary.
- 3CPAP intolerance or failure: You have tried and failed CPAP therapy, or CPAP is contraindicated. (Documentation required.)
- 4Custom fabrication: The appliance is custom-made by a qualified dentist specifically for sleep apnea treatment.
- 5Face-to-face visit: You have a face-to-face clinical evaluation within the last 12 months with the treating physician or qualified provider.
What You'll Pay with Medicare
Medicare Part B Coverage
Medicare pays 80% of the Medicare-approved amount for the appliance and related services after you meet your annual Part B deductible ($240 in 2024).
Your Responsibility
You're responsible for the remaining 20% coinsurance, plus the Part B deductible if not yet met. Medicare Supplement plans (Medigap) may cover some or all of this amount.
Example: If the Medicare-approved amount for your oral appliance is $2,000, and you've met your deductible, Medicare pays $1,600 (80%) and you pay $400 (20%).
Important Medicare Notes:
- • Medicare Advantage plans may have different coverage rules—check with your specific plan
- • Documentation of CPAP trial and failure is typically required
- • We handle all Medicare paperwork and authorization on your behalf
Commercial Insurance Coverage
Most private health insurance plans cover sleep apnea testing and oral appliance therapy. Coverage levels and requirements vary by plan, but the general framework is similar across major carriers.
Typical Coverage
- • 50-80% coverage after deductible
- • Some plans cover 100% after deductible
- • Follow-up visits often covered at office visit rate
- • Replacement appliances covered every 3-5 years
Common Requirements
- • Sleep study diagnosis of OSA
- • Physician prescription
- • Prior authorization (we handle this)
- • Treatment by qualified dentist
Major Insurance Carriers We Work With:
Don't see your insurance listed? Call us at (503) 922-1166 to verify coverage.
HSA & FSA Eligibility
Tax-Advantaged Payment Options
Oral appliance therapy for diagnosed sleep apnea is an eligible expense for both Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA).
What's Covered:
- Sleep apnea testing (HSAT or in-lab study)
- Custom oral appliance fabrication and delivery
- Follow-up consultations and adjustments
- Any out-of-pocket costs after insurance
Tax Savings:
Using pre-tax HSA or FSA funds can save you 20-30% on out-of-pocket costs, depending on your tax bracket. For example, if your out-of-pocket cost is $500, using HSA/FSA could save you $100-$150 in taxes.
Prior Authorization Process
Many insurance plans require prior authorization before approving oral appliance therapy. This is a standard process to verify medical necessity. We handle the entire prior authorization process for you.
We Submit Request
After your initial consultation, we submit a prior authorization request to your insurance company with all required documentation: sleep study results, physician prescription, medical records, and treatment plan.
Insurance Review
Your insurance company reviews the request to determine medical necessity. This typically takes 3-10 business days, though some plans provide same-day or 24-hour decisions.
Authorization Received
Once approved, we receive an authorization number and coverage details. We'll contact you with your estimated out-of-pocket costs and schedule your next appointment.
Treatment Begins
With authorization in hand, we proceed with impressions and appliance fabrication. You'll know your financial responsibility upfront—no surprises.
What If Authorization is Denied?
While rare, denials can happen. If your authorization is denied, we will:
- • Review the denial reason with you
- • Work with your physician to provide additional documentation
- • File an appeal on your behalf
- • Explore alternative coverage pathways
- • Discuss self-pay options and payment plans if needed
How We Help With Insurance
Before Treatment
- Verify your insurance benefits and coverage
- Determine your deductible and out-of-pocket maximum
- Provide upfront cost estimate based on your plan
- Submit prior authorization requests
- Coordinate with your physician for required documentation
During & After Treatment
- File all insurance claims electronically
- Follow up on claim status and payment
- Resubmit claims if initially denied
- Assist with appeals if necessary
- Provide itemized statements for your records
- Answer any billing or insurance questions
Estimated Out-of-Pocket Costs
While costs vary based on your specific insurance plan, deductible, and coinsurance, here are typical out-of-pocket ranges patients experience:
| Service | Total Cost | Typical Insurance Coverage | Est. Out-of-Pocket |
|---|---|---|---|
| Home Sleep Test (HSAT) | $150-$500 | 70-100% | $0-$150 |
| Initial Consultation | $150-$300 | Office visit copay | $20-$100 |
| Oral Appliance (total) | $2,000-$3,500 | 50-80% | $300-$800 |
| Follow-up Adjustments | $75-$150 each | Office visit copay | $20-$50 |
| Follow-up Sleep Study | $150-$500 | 70-100% | $0-$150 |
Important Notes:
- • These are estimates only; actual costs depend on your specific insurance plan
- • If you haven't met your annual deductible, you may pay more initially
- • Once you reach your out-of-pocket maximum, insurance typically covers 100%
- • We provide an exact cost estimate after verifying your specific benefits
Payment Plans & Financing
We believe everyone deserves effective sleep apnea treatment, regardless of insurance coverage. That's why we offer flexible payment options to fit your budget.
In-House Payment Plans
- • No interest or credit check required
- • Spread payments over 3-12 months
- • Flexible payment schedules
- • Small down payment required
- • Automatic monthly payments available
Third-Party Financing
- • CareCredit and other healthcare financing
- • 0% interest promotional periods available
- • Extended payment terms up to 24 months
- • Quick online approval process
- • Multiple plan options to fit your needs
No Surprises
We'll discuss all payment options during your initial consultation and create a plan that works for your budget. Treatment cost should never prevent you from getting the care you need.
Our Insurance Verification Process
When you schedule your initial consultation, here's what happens with your insurance:
You Provide Information
When you schedule, we collect your insurance information (carrier name, policy number, group number).
We Verify Benefits
Our team contacts your insurance company to verify coverage, deductible status, coinsurance percentage, and any prior authorization requirements.
You Receive Estimate
Before your appointment, we'll provide a detailed breakdown of expected insurance coverage and your estimated out-of-pocket costs.
Treatment Proceeds
With financial clarity, we move forward with your treatment plan. We file all claims and handle all insurance communication.
Questions about your specific coverage? Call our office at (503) 922-1166 and our insurance specialists will be happy to help.