Continuous Positive Airway Pressure (CPAP) therapy is one of the most common treatments for obstructive sleep apnea. Obstructive sleep apnea is a condition that causes breathing problems and reduced oxygen levels. It can range from mildly annoying to a serious medical condition.
For seniors who have been diagnosed with sleep apnea, CPAP therapy can be a vital treatment method that greatly improves quality of life. You may have questions about whether or not CPAP therapy is covered by Medicare.
Medicare CPAP Compliance
Medicare can and will cover CPAP therapy for a three-month trial or longer, provided your doctor provides proper documentation that the treatment is helping you and that you meet specific requirements.
CPAP therapy does not work for everyone, so Medicare typically covers the use of a CPAP machine for an initial three-month trial. If your doctor determines CPAP therapy is helping your condition, Medicare may choose to extend coverage. Being in Medicare compliance means that you’re using the equipment as prescribed by your doctor.
After the conclusion of the trial, you’ll owe 20% of the Medicare-approved cost for rental of the CPAP machine. After 13 months of rental (and Medicare payment), you’ll own the machine outright. If you used a CPAP machine prior to enrollment in Medicare, Medicare may cover replacement CPAP machine rental costs—provided you meet certain requirements.
Does Medicare cover sleep studies?
Medicare Part B—the medical insurance portion—does cover Type I, II, III, and IV sleep tests and devices. Note that, like many other covered services, you’ll pay 20% of the Medicare-approved amount after you meet your Part B deductible. Doctors may require an at-home sleep apnea test. They may also require you to go through a formal overnight lab sleep study at a clinic.
How often will Medicare pay for a new CPAP machine?
Medicare will generally pay for CPAP machine replacement every five years. Medicare can also pay 80% of the cost for replacement supplies. The Part B deductible will still apply. Replacement supplies for CPAP machines include:
- One full face mask every three months
- One full face cushion per month
- Two nasal cushions per month
- New headgear every six months
- A new chinstrap every six months
- New tubing every three months
- Two disposable filters per month
- One non-disposable filter every six months
If you need replacement supplies outside of this schedule, Original Medicare typically will not pay for items or services. For Medicare Advantage plans, you’ll want to check with your insurance company for more information.
Are CPAP machines considered Durable Medical Equipment?
CPAP machines are considered Durable Medical Equipment (DME), which means that they’re covered by Medicare. DME must be durable, used for a medical reason and used in your home. DME should not be useful to someone who is well.
Even though CPAP machines count as DME, there are a few things you should note when shopping for your equipment. Medicare will only cover it—and other DME—if the doctors and suppliers are enrolled in Medicare. If they’re not, Medicare will not pay any claims submitted by them.
The best time to ask a supplier or doctor about their enrollment in Medicare is before you get your equipment. Suppliers who participate in Medicare must accept assignment. Assignment means they can charge you only the coinsurance and Part B deductible. If a supplier does not participate, there is no limit to what they can charge you; save money, time and headache by working exclusively with suppliers who accept Medicare.
Are CPAP cleaners covered by Medicare?
Unlike CPAP machines themselves or their tubing, masks or replacement parts, CPAP cleaners aren’t covered by Medicare. Because CPAP cleaners and sanitizers aren’t considered DME, they’re not eligible for coverage. They can, however, be purchased with HSA/FSA funds. Always read the rules carefully for your specific health policy to ensure your HSA or FSA funds can be used to purchase any equipment or pay for services.
In addition to not paying for cleaning machines, Medicare usually won’t help pay for things like mask liners, mask wipes, hose holders or tube covers. Many of these items are expensive, so buy with care.
Review your Medicare Coverage with SelectQuote
If your doctor has ordered a sleep test and/or CPAP therapy for sleep apnea, you’ll want to be sure that your Medicare coverage can help pay for your treatment and medical care. If you have questions about Medicare or would like a licensed insurance agent to help review your current coverage, SelectQuote can help.
We can help walk you through a variety of Medicare Supplement plans and Medicare Advantage options to help find coverage that can meet your needs at a price that fits your budget.