Snoring problems andsleep apnea Obstructive sleep apnea (OSA) is not a minor issue that should be overlooked. Besides its long-term health consequences, such as heart disease and high blood pressure, the cost of treatment, especially a CPAP machine (positive pressure air machine), is a significant barrier that makes many people hesitant to seek treatment.

A question many patients wonder is: “"Is a CPAP machine covered by social security?"” or “"If I want to take a Sleep Test, do I have to pay for everything myself?"”

Good news for all insured individuals! Effective January 1st, 2024, the Social Security Office has announced a new benefit allowing insured individuals to claim reimbursement for Sleep Test and CPAP machine costs. This will significantly reduce your expenses. This article from NK Sleepcare will take you through all the conditions, reimbursement procedures, and tips on protecting your rights to ensure you receive the highest quality treatment at the lowest possible cost.

Is a CPAP machine covered by social security insurance? (Latest update)

The answer is... “"Reimbursable"” Yes, and this marks a significant change in the field of sleep medicine in Thailand.

Previously, CPAP treatment might have been considered an auxiliary or specialized device that patients had to bear the cost of themselves. However, the Social Security Office has now recognized the importance of sleep apnea, which is the root cause of many serious illnesses, and has therefore made CPAP diagnosis and treatment a benefit accessible to insured persons under Section 33 and Section 39.

This change is effective from... January 1, 2024 Going forward, this covers the cost of diagnostic tests (Sleep Test), treatment equipment (CPAP machine), and supplementary equipment (mask), under specified medical conditions and indications.

Social security benefits for CPAP treatment.

To help you understand the coverage limits and benefits clearly, we have summarized the benefits into three main sections as follows:

1. Sleep testing (Polysomnography)

Before you can be reimbursed for a CPAP machine, you need medical confirmation that you actually have sleep apnea. This is done through a sleep test. Social Security covers the cost of this test as follows:

Sleep Test Type 1 (Full Polysomnography): A complete monitoring process with overnight surveillance is the gold standard and the most accurate method. Maximum reimbursement is 7,000 baht.
Sleep Test Type 2: This test measures similar values to type 1 but without a caretaker (often done at home or in a hospital). Reimbursement is based on actual expenses, but not exceeding 7,000 baht. (Subject to the doctor's discretion and the rights of the hospital.)

Caution: This Sleep Test reimbursement covers medical services and hospital room charges at public or private hospitals contracted with the social security system. Any difference beyond this amount may need to be paid additionally by the insured person.

2. CPAP machines that are reimbursable through social security.

This is the part that can help reduce the cost the most for those who have been diagnosed with needing a ventilator:

CPAP machine cost limit: Social security covers the cost of CPAP (Continuous Continuous Air Pressure) machines up to a specified limit. 20,000 baht
Important conditions:
1. The patient must be unable to be treated surgically, or the surgery was ineffective.
2. The doctor has diagnosed an urgent need or the apnea coma index (AHI) is higher than the set threshold.

3. CPAP masks and related equipment.

A CPAP machine will not function at all without a proper mask, which is an item that deteriorates over time.

Cost of a mask: Reimbursable. 4,000 baht Per piece
Disbursement cycle: You can request one new mask per year (subject to continuous use conditions).
Other accessories: For example, air filters or ducts are often included in the medical service fee or equipment cost, depending on the case.

In-depth look at medical conditions: Who is eligible for CPAP machine reimbursement?

Not everyone who snores can immediately request a CPAP machine. Medical and social security authorities have established "indications" to screen patients who truly need it, as follows:

1. Severity level of the disease (measured by the AHI value)

Doctors will consider the AHI (Apnea-Hypopnea Index), or the index of breathing apnea and shortness of breath per hour, which is obtained from the results of a sleep test.

Group 1: AHI value greater than 15 times/hour.
This group is considered to have moderate to severe OSA (Obstructive Thrombosis Arthritis) and is immediately eligible for a CPAP machine because of the high health risk if left untreated.
Group 2: AHI values between 5 and 15 times/hour.
This group is considered to have a mild OSA (Mild OSA) level and is only eligible for reimbursement if... Do you have any underlying medical conditions or complications? namely:
- Cardiovascular disease (Coronary Artery Disease)
- High blood pressure (Hypertension)
- Stroke
- Congestive Heart Failure

2. Passed an evaluation by a specialist physician.

Prescriptions for CPAP machines must be signed off by a respiratory and critical care physician, an ENT physician, or a pediatric respiratory physician to confirm that CPAP treatment is most appropriate for that particular patient.

Who is eligible to use a CPAP machine for social security benefits?

This right is no longer limited to civil servants but is open to private sector employees and voluntary insured persons, subject to the following conditions:

Insured persons under Section 33: Employees who work in establishments with employers.
Insured persons under Section 39: Those who were previously under Section 33 and voluntarily continue to make contributions.
Contribution payment conditions: Contributions to the social security fund must have already been made. Not less than 3 months within a period of 15 months. Before the medical service date.

note: For insured persons under Section 40 (self-employed), the benefits currently do not cover the same as those under Sections 33 and 39. It is recommended to check with the hotline 1506 again.

Where can I use my social security benefits for CPAP treatment?

To claim your benefits, you must receive services at an authorized medical facility to ensure a smooth reimbursement process.

1. Medical facilities covered by social security insurance.

You must start by visiting a doctor at the hospital of your choice that is covered by your insurance (check the SSO Connect app or the Social Security website) so that the doctor can conduct an initial assessment of your condition.

2. In case of referral to another medical facility for treatment.

If the hospital covered by your insurance does not have a sleep center or no specialist doctors, the hospital will issue... “"Transfer letter"” This allows you to undergo a sleep test or receive a CPAP machine at a higher-capacity hospital (such as a university hospital or regional hospital) without having to pay upfront, or only paying the difference as agreed upon.

Duration of entitlements and important information about "continuity".“

The social security system wants to ensure that the reimbursed medical equipment is "actually being used" and benefits patients' health, hence the strict regulations regarding the renewal of benefits.

The golden rule of replacing your device (every 5 years).

CPAP machines have a lifespan, but to be eligible for a replacement, you must provide proof of consistent use.

The machine must be used at least once. 4 hours a day
It needs to be used very consistently. 70% of the total number of days. Over a period of 3 consecutive months.

Rules for replacing face masks (once a year).

Similar to the device itself, when requesting a new mask in the following year, you must attach the Compliance Report from the device to prove that you have continued to receive treatment.

The machine must be used at least once. 4 hours a day
It needs to be used very consistently. 70% of the total number of days. Over a period of 3 consecutive months.

Expert advice: Popular and effective CPAP machine models include: ResMed AirSense 10 or Philips DreamStation Sleep data will be recorded onto an SD card, or you can bring the device to NK Sleepcare. We offer services for downloading and printing machine usage reports.To prepare a report for the doctor to use for reimbursement purposes.

Steps for claiming Social Security benefits for Sleep Tests and CPAP machines.

Step 1: Consult a doctor and get your symptoms assessed.

Go to the hospital covered by your insurance and inform the doctor about symptoms such as snoring, sleep apnea, or excessive daytime sleepiness. The doctor will take your medical history and perform a physical examination.

Step 2: Take a Sleep Test and receive a diagnosis.

If your doctor suspects OSA (Obstructive Sleep Apnea), you will be referred for a Sleep Test (reimbursable up to 7,000 baht). Once the results are available, your doctor will interpret the AHI (Acute Health Intensive Care) and summarize the treatment plan.

Step 3: Request approval to use a CPAP machine according to your eligibility.

If the results meet the criteria (AHI > 15 or there are complications), your doctor will issue a prescription for CPAP treatment. Take this prescription to the hospital's benefits department to process the reimbursement for the device (up to 20,000 baht).

Step 4: Select the machine and start using it.

At this stage, the hospital may offer a choice of devices, or you may be asked to take your doctor's prescription to a certified distributor (such as NK Sleepcare). The hospital will then handle the cost with social security, or you may pay upfront and then claim reimbursement with the receipt (depending on the regulations of each hospital).

Is a CPAP machine covered by social security benefits worthwhile?

Many of you may wonder... “"Is 20,000 baht sufficient?"”

To be honest, high-quality CPAP machines with comprehensive features (such as automatic pressure regulation (Auto CPAP), humidifier systems, or online monitoring) typically have a market price range of 30,000 – 50,000 baht or more.

Case 1: Using a budget-friendly model (Manual CPAP).

There may be some models available for around 20,000 baht or slightly more, but these are usually fixed-pressure systems, which may cause some patients discomfort during exhalation and lack detailed data recording capabilities.

Case 2: Use your entitlement as a discount to purchase a standard model machine (Auto CPAP). This is the most cost-effective option. You can choose high-quality machines, such as: ResMed AirSense 10 AutoSet or Philips DreamStation Auto The cost is approximately 39,000 – 65,000 baht, and then 20,000 baht can be claimed using social security benefits. You only need to pay the difference of 19,000 – 45,000 baht yourself. only

Why is paying the difference more worthwhile?

Comfort: An Auto CPAP machine adjusts airflow according to your actual breathing rhythm, reducing discomfort and allowing you to sleep longer.
Follow-up: Standard models can easily generate reports to verify eligibility for future equipment requisitions.
Durability: Leading brands like ResMed or Philips have a lifespan of 5-10 years, making them worthwhile in the long run.

summarize

The fact that the Social Security system now covers the cost of Sleep Tests and CPAP machines opens the door for Thais to access internationally standardized treatment. Snoring and sleep apnea are not just annoyances; they are silent killers that can be fatal.