Millions of people in the United States suffer from obstructive sleep apnea (OSA). It's a condition that causes repeated lapses in breathing during sleep, which can prevent the body from getting enough oxygen. The condition can be dangerous if left untreated.
The good news is that there are effective treatments for sleep apnea, including continuous positive airway pressure (CPAP) therapy. A CPAP machine is a medical device that keeps your airways open during sleep so your breathing isn’t interrupted. It’s estimated that 33 million adults depend on one.
But the question is, does Original Medicare (Parts A and B) cover CPAP machines? The answer is yes. Part B (medical insurance) is the portion of Original Medicare that helps pay for durable medical equipment (DME), which includes CPAP machines and supplies. Here’s what you need to know.
When Will Medicare Cover CPAP Machines?
In order to qualify for Part B coverage of CPAP equipment, you must meet the following requirements:
- Your doctor diagnoses you with OSA based on the results of a sleep study. Your sleep study can take place either in person or through an approved at-home sleep test.
- Your doctor and machine provider participate in Medicare.
- You are current on your Part B premiums and have met your deductible.
Part B will typically pay for a three-month test of CPAP therapy to see if you benefit. This includes the CPAP device and any accessories you need for it.
Once your trial period ends, Medicare may continue the coverage if you have used the machine consistently and your doctor determines it’s helping. If you had a CPAP machine before you joined Medicare, it might pay for you to rent a new one or get accessories if you meet certain requirements.
Whether or not your doctor prescribes CPAP therapy will depend on your condition and the severity. If your sleep apnea is mild, your doctor may recommend lifestyle changes or a mouth guard before committing to CPAP therapy. But if your sleep apnea is moderate to severe, your doctor may prescribe it right away.
How Much Does Medicare Pay for a CPAP Machine?
Medicare pays 80% of the approved amount to rent a CPAP machine for 13 months. Once you meet your Medicare Part B deductible, you’ll pay the remaining 20%. After Medicare makes rental payments for 13 continuous months, you’ll own the machine.
Again, Medicare will only cover your CPAP machine and other DME if your doctors and suppliers are enrolled in Medicare. If a DME supplier doesn't accept the assignment, there’s no limit on the amount they can charge you. You may also have to pay the entire bill (your share and Medicare's share) at the time you get the DME.
If you have Medicare Part C (Medicare Advantage), your plan must offer at least the same level of coverage as Medicare Part B and may offer additional benefits as well.
Does Medicare Pay for CPAP Supplies?
Medicare helps pay for the accessories needed for a CPAP machine, such as tubes, filters, humidification chambers and masks. To make sure Medicare helps with the cost, your retailer needs to be approved by Medicare and you'll need to pay 20% of the cost. Most of these items can be replaced regularly if you follow Medicare rules on how often you can get them.
Since CPAP supplies can get dirty and lose effectiveness over time, Medicare covers replacement supplies on a regular schedule as well. Depending on the item, you may need replacements anywhere from every two weeks to every six months.
Getting a good night’s sleep is crucial to your health, so it’s important to get checked if you suspect you have sleep apnea. Using a CPAP machine consistently can help you get the oxygen you need while you sleep so you can rest easily and have more energy during the day.
How often am I eligible for a new CPAP machine?
Medicare will typically cover a new CPAP machine once every five years. This is the expected lifetime of most CPAP devices. Medicare covers replacement supplies on a regular schedule as well since they can get worn out and lose effectiveness over time. Depending on the item, you may need replacements every two weeks to every six months. Talk with your DME provider about getting set up on a Medicare compliant replacement schedule.
Questions? Learn more about Wellcare Medicare Advantage plans and what may be covered to help treat your sleep apnea.
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Sources
What Is Sleep Apnea?
National Council on Aging - Sleep Apnea Statistics
Medicare.gov - CPAP Coverage
CMS.gov - CPAP Therapy for OSA
National Council on Aging - Does Medicare Cover CPAP Machines?
