The Ultimate AirSense 11 Payment Strategy: When to Use Insurance (And When It's Smarter to Pay Cash)

You have your prescription for a Resmed AirSense 11. You're ready to finally get a good night's sleep. You go online to look up the machine and... sticker shock.

You see a price tag that can be close to $1,000. Your first thought is, "My insurance will cover this, right?"

The answer is... it's complicated. But we at The CPAP Shop can help!

As insiders in the CPAP industry, we see patients navigate this exact problem every day. The truth is, the "best" way to pay depends entirely on your specific insurance plan, your deductible, and whether you value privacy and freedom over paperwork.

This guide isn't just a list of prices. It's a strategic plan. We'll show you the three paths to getting your machine so you can make the smartest financial decision for you.

Here is the most important concept you need to understand: The price you see on a retail website like ours (the "cash price") is not the same as the price an "in-network" insurance provider will bill (the "insurance price").

• The "Cash Price": This is the simple, transparent price you see at thecpapshop.com. We can offer this price because it's a straightforward retail transaction. There is no complex insurance paperwork, no billing department to chase claims, and no staff dedicated to monitoring your compliance.
• The "Insurance Price" (or "Allowable Amount"): This is the (often inflated) price a traditional, in-network Durable Medical Equipment (DME) provider bills to your insurance company. This price has all of that administrative cost baked in—the staff, the billing, the compliance-chasing.

Why does this matter? Because if you have a high deductible, you could lose money by using your insurance.

Let's look at a very common scenario for someone with a High-Deductible Health Plan (HDHP).

• Price Billed by In-Network DME for E0601 (CPAP): $1,800
• Insurance "Allowed Amount": $1,000
• Your Remaining Deductible: $3,000
•  Insurance Pays (0%): $0
• YOU OWE (to your DME): $1,000

In this example, the patient used their insurance but still paid the full $1,000 allowed amount because they hadn't met their deductible. If the cash price on our site was $950, that patient would have saved $50 (and weeks of paperwork) by simply paying cash and not involving insurance at all.

Paying out-of-pocket might feel wrong, but it is frequently the fastest, cheapest, and most private way to get your AirSense 11.

This is the most common reason. As the example above shows, if your remaining deductible is higher than the cash price of the machine, you will pay 100% of the cost either way. Always compare our cash price to your remaining deductible.

This is a benefit most people don't consider.

• When you use insurance, you are required to prove you are using the machine. This is called compliance. You must use it for at least 4 hours per night, for 70% of the nights.
• Your AirSense 11 (via the myAir app) reports this data directly to your insurer. If you fail to be compliant, they can stop covering your supplies or, in some cases, even ask for the machine back.
• When you pay cash, the machine is YOURS. Period. No one is monitoring your data except for you and your doctor. You have the freedom to use it when you travel or take a night off without worrying about an insurance company looking over your shoulder.

Insurance will almost never pay for a "backup" machine or a smaller, dedicated travel CPAP (like the Resmed AirMini). If you want a second machine for a vacation home, for travel, or just for peace of mind, paying cash is your only option.

If you have a great, low-deductible plan, using insurance might be the right call. Here is your action plan to find out for sure.

Step 1: Get Your Insurance Codes
Your prescription is for an "AirSense 11," but your insurance company thinks in billing codes.

• E0601: This is the code for a CPAP device.
• A7030: Full Face Mask
• A7034: Nasal Mask
• A7035: Headgear

Step 2: Call Your Insurer (Your "Script")
Pull out your insurance card, call the member services number, and ask these exact questions.

My Insurance Phone Script:

1. "I have a prescription for a CPAP device, code E0601. Is this covered under my plan as 'Durable Medical Equipment' (DME)?"
2. "What is my remaining deductible for in-network DME?"
3. "After my deductible is met, what is my co-insurance?" (This is the percentage you still have to pay, e.g., "I pay 20%").
4. "What are my compliance requirements to ensure continued coverage for the machine and for my future supplies?"
5. (The Key Question for Us): "What are my out-of-network benefits for DME? If I buy my machine from an online provider like thecpapshop.com and submit the receipt, how does reimbursement work?"

A Note on "Out-of-Network": We (The CPAP Shop) are an out-of-network provider for most private insurance plans. This means you pay us the cash price, and we provide you with a detailed receipt that you can submit to your insurance plan for potential reimbursement.

Medicare is a completely different process. It's not a simple purchase; it's a long-term rental.

The Process: Medicare Part B covers CPAP machines as a 13-month "rent-to-own" program.

• You will get your machine from a Medicare-approved DME supplier.
• For 13 straight months, Medicare pays 80% of their approved monthly rental fee.
• You (or your Medigap/supplemental plan) are responsible for the other 20% each month.
• After 13 months of payments, you own the machine.

The "Big Warning": The 90-Day Compliance Gauntlet

Medicare's compliance rules are strict and non-negotiable.

• You must prove you are using your machine within the first 90 days of starting therapy.
• If you fail to meet the compliance goals (4+ hours/night for 70% of nights), Medicare will stop paying.
• When Medicare stops paying, the DME provider (who still technically owns the machine) has the right to take the machine back, and you are left with nothing

Many of our customers who are on Medicare still choose to pay cash for their machine to avoid this 13-month rental and the stress of the 90-day compliance gauntlet.

Our team of CPAP experts can't call your insurance company for you, but we can help you do the math. If you're still confused, call us or start a chat. We'll help you understand all your options to get the therapy you need, the way you want it. Contact us today!

Extra Buying Tip! The CPAP Shop accepts both HSA/FSA! Use your 'use-it-or-lose-it' FSA funds to buy supplies (filters, cushions) at our cash price.