Does Medicare Cover CPAP Machines?
Yes, Medicare does cover CPAP machines as durable medical equipment (DME) under Medicare Part B. To gain eligibility, patients must participate in sleep tests proving they have obstructive sleep apnea (OSA), receive a CPAP prescription from a doctor affirming the treatment as medically necessary, and rent the device through a Medicare-approved supplier.
Medicare Part B will cover 80% of any Medicare-approved CPAP machine and all applicable replacement supplies, such as face masks and tubing. Medicare CPAP coverage will last at least three months and can extend much longer if your doctor corroborates you have continuously used the machine as prescribed and show clear signs of improvement.
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Who Needs Continuous Positive Airway Pressure (CPAP) Machines?
Continuous positive airway pressure (CPAP) machines deliver a steady flow of oxygen to the nose and mouth of sleeping patients. Though CPAP machines primarily treat obstructive sleep apnea (OSA), they occasionally get prescribed to manage common breathing disorders and other types of sleep apnea, including:
- Central sleep apnea (CPA)
- Sleep-related hypoventilation
- Sleep-related hypoxemia
- Cathathernia, or sleep-related groaning
- Underdeveloped lungs in preterm babies
Experts estimate that 3-9% of the general population suffers from OSA. The lack of restful sleep and low oxygen levels resulting from this condition can lead to other dangerous issues like resistant hypertension, cardiovascular disease, diabetes, and liver problems, making Medicare CPAP coverage essential for at-risk members.
Understanding Medicare Coverage for CPAP Machines
Medicare defines DME as any materials or supplies ordered by your healthcare provider for everyday or extended use. Common examples include crutches, hospital beds, nebulizers, wheelchairs, and blood testing strips. Because patients use CPAP machines every night for months or years, they qualify as DME under Medicare Part B.
If you have been diagnosed with OSA, Medicare will initially cover a three month trial of CPAP therapy. After this trial period, patients must meet with a doctor in person. If their physician can prove that treatment has shown positive results and that continued care is medically necessary, CPAP Medicare coverage can continue indefinitely.
To become eligible for a Medicare-covered CPAP machine, you must meet the following requirements:
- You have enrolled in Medicare Part B and stayed up-to-date on monthly premiums.
- You have undergone a professional sleep study resulting in an OSA diagnosis.
- A Medicare-compliant doctor prescribes a CPAP machine as medically necessary in treating your OSA.
- You purchase or rent your device through a Medicare-approved DME supplier.
Once approved, you can begin your three month CPAP trial period. As mentioned above, Medicare may continue to pay for your machine and replacement parts beyond this window, given that you have followed CPAP compliance rules, show improving signs of health, and require continued therapy to manage your OSA.
Part B Coverage
Medicare Part B covers 80% of all eligible medical procedures, tests, and DME, including medically necessary CPAP machines. Typically, Medicare will pay to rent a device from a Medicare-compliant supplier for 13 consecutive months, after which patients can own the machine. Once they meet their Part B deductible, Medicare members are responsible for paying the remaining 20% coinsurance out-of-pocket.
Original Medicare members can purchase private Medicare Supplement, or Medigap, policies to help fill in the coverage “gaps” left by copays, coinsurance, and deductibles. For example, after Medicare Part B covers 80% of your CPAP machine upfront, some Medigap policies will fully pay your remaining Part B coinsurance and deductible.
CPAP Accessory Coverage
CPAP machines require joint use with various compatible accessories to function as intended. Once a doctor approves CPAP therapy as medically necessary, Medicare Part B will also cover 80% of the Medicare-approved amount for essential CPAP supplies, including:
- CPAP tubing with an attached heating element
- Face masks
- Humidifier water chamber
- Oral and nasal pillows
The longer you undergo treatment, the more likely you will need to replace or repair some of these accessories. Medicare Part B will pay for equipment upgrades on a timeline that meets a “basis of medical necessity.” For example, Medicare will cover two oral replacement cushions per month but only one CPAP heating tube every three months.
How Does Medicare Advantage Cover CPAP Machines?
Medicare Advantage, or Medicare Part C, is an alternative to Original Medicare in which eligible seniors purchase Medicare coverage through private insurers. Medicare Advantage policies must offer all the same protections of Original Medicare Part A and Part B, though they often include supplementary benefits like vision, dental, and prescription care.
By law, all Medicare Advantage plans must cover medically necessary CPAP machines and accessories for patients who meet the standard eligibility requirements. However, since private companies oversee these policies and set independent rules and cost-sharing expectations, out-of-pocket deductible and copay expenses will vary from plan to plan.
How Much Do CPAP Machines Cost with Medicare?
On average, CPAP machines cost around $760. If you qualified for Medicare-covered CPAP therapy and purchased a device through a Medicare-approved supplier, you would only have to pay 20% of the final cost after meeting your annual $226 Part B deductible. For example, if you needed a $760 machine and paid your deductible earlier in that same calendar year, you would only owe a $152 coinsurance.
CPAP accessory replacement and repair costs can also quickly stack up without coverage. On average, CPAP masks cost around $106, heated tubing costs $49, and chin straps cost $17 each. Replacing these every three months would cost $172. Comparatively, Original Medicare members would only pay $34 out-of-pocket for the same supplies.
Medicare Advantage Costs
Medicare Advantage CPAP therapy costs vary widely from plan to plan. Instead of the typical 20% Part B coinsurance, Medicare Advantage plans usually charge policy specific copays for doctors’ services and DME. Medicare Advantage also allows its providers to set independent deductibles. Given these inconsistencies, Part C recipients should contact the companies overseeing their plans and clarify their cost-sharing responsibilities before purchasing a CPAP machine.
How to Get Medicare to Cover Your CPAP Machine
If you suffer from OSA, follow these steps to secure a Medicare-covered CPAP machine:
- Obtain a diagnosis: You must undergo a professional in-lab or at-home sleep study to prove you have OSA.
- Get a prescription from your doctor: Prescriptions must affirm that CPAP therapy is medically necessary for treatment to qualify for Medicare coverage.
- Find a Medicare-approved supplier: Not all DME suppliers accept Medicare assignment. Members must pay for devices and accessories from non-compliant dealers entirely out-of-pocket.
- File the claim: Typically, the DME supplier will comp 80% of your Medicare-approved amount and personally file a Medicare claim to receive reimbursement.
- Pay your share: Once the supplier approves your coverage, pay your 20% coinsurance to secure your CPAP machine and begin treatment.
The Benefits of CPAP Machines
By simply facilitating nighttime breathing, CPAP machines offer the following medical benefits:
- Healthier sleep
- Improved mental health, emotional stability, and concentration
- Less daytime sleepiness
- Reduced snoring
- Lower risk of developing severe conditions like hypertension, heart disease, diabetes, liver problems, neurological damage, or even death
CPAP machines can also improve your relationships, as thunderous snoring often disrupts the lives of residential family members, roommates, or romantic partners. Above all, most experts believe that restful sleep is equally essential to diet or exercise in living an all-around happier and healthier life.
If you do not qualify for a Medicare-covered CPAP machine, you can explore the following alternatives:
- BiPAP Machine: Unlike CPAP machines, bilevel-positive airway pressure devices allow patients to set independent pressure levels for inhaling and exhaling. Because BiPAP machines primarily treat central sleep apnea, doctors will only prescribe them for OSA patients who cannot tolerate traditional CPAP therapy.
- EPAP Machine: Expiratory positive airway pressure therapy generates oxygen by using nasal devices to recycle a patient’s breath. EPAP machines come travel-sized and do not require electricity, making them a viable alternative for OSA patients on the go.
- APAP Machine: Auto-adjusting positive airway pressure devices mechanically respond to changes in users’ breathing patterns. Though APAP machines offer all the benefits of CPAP therapy, they tend to cost more due to the extra comfort provided by their advanced sensors.
Most of all, try changing certain personal habits. A large body of research has tied conditions like sleep apnea to alcohol consumption, lack of exercise, poor diet, and ineffective sleeping positions.
Putting It Together
Living with OSA affects an individual’s energy levels, mental facilities, and personal relationships and can lead to more significant health problems like heart disease and diabetes. Luckily, if a sleep test proves you suffer from OSA and a doctor prescribes CPAP therapy as a medical necessity, Medicare will cover most CPAP machine expenses and any required accessories.
CPAP therapy has proven incredibly effective in managing OSA and improving patients’ overall health and quality of life. If you cannot manage your OSA through diet, exercise, and substance moderation, talk to a Medicare agent about your CPAP eligibility and schedule a sleep test to initiate coverage and begin treatment.