Over 18 million Americans have some form of sleep apnea, and some need a Continuous Positive Airway Pressure (CPAP) machine. If you are enrolled in Medicare and are one of these millions of people with sleep apnea, you might be wondering if a CPAP machine is covered under the Durable Medical Equipment benefits of Part B. The simple answer to this question is yes, but with some caveats. In some cases, Medicare only covers a three month trial for CPAP therapy, but you can get it covered for longer as long as you meet certain criteria.
What Is A CPAP Machine?
Obstructive sleep apnea (OSA) that is left untreated can lead to high blood pressure and possibly even congestive heart failure. If you are suffering from this dangerous condition, you will be evaluated to see whether you need a CPAP machine to help you breathe more easily while sleeping. This machine, which has an attached mask that you wear while sleeping, produces air pressure in your throat. The air pressure it produces is higher than that of the room’s air, which will help to keep your upper airway open. Before prescribing a CPAP machine, your doctor will speak to you about how long you’ve had symptoms of sleep apnea, and will assess your symptoms to see if you are a good candidate for this type of therapy.
When Medicare Will Cover CPAP
If you are diagnosed with obstructive sleep apnea, Medicare will cover a 3-month trial of CPAP therapy as long as you:
- Meet face-to-face with a treating physician to receive a clinical evaluation prior to a sleep test assessment.
- Complete a sleep test in a laboratory, or use an approved at-home test.
- Have a prescription for a CPAP machine from your doctor.
- Get a CPAP machine from a participating Medicare supplier and receive instruction from the CPAP supplier about the proper use and care of the CPAP machine
In order for your machine to be covered for longer than the 3-month trial period, you have to use the machine more than 4 hours a night for at least 70% of nights within a consecutive 30-day period. Once you are successful with a 3-month trial of the CPAP, Medicare might continue coverage as long as you meet in person with your doctor, and your doctor documents in your medical records that the CPAP is helping you. Once that is in your medical records, Medicare will cover an additional 10 months of the machine rental.
How Much Is Covered By Medicare?
Medicare will help pay for your rental of a CPAP machine for a total of 13 months as long as you use it continuously for that time. After you are done renting it for a total of 13 months, you will own the CPAP machine.
You will need to meet your Medicare Part B deductible before Medicare pays its share of your CPAP equipment. Medicare Part B (which covers durable medical equipment) will then cover 80% of the cost, meaning you will have to pay a 20% coinsurance for the CPAP machine. Tubing, face masks, filters, and other supplies for the machine are also covered at 80%.
If your CPAP supplies get dirty or lose effectiveness, Medicare will cover replacement supplies. Depending on the part, you might need to replace it every two weeks to every six months.
Medicare Supplement Plan
If you have a Medicare Supplement Plan, your plan might cover your CPAP coinsurance payment. It will also help pay for the coinsurance of your CPAP supplies. Each plan has its own cost and coverage options. If you do not have a Medicare Supplement Plan already, EZ can help you to find a plan that covers a CPAP machine and equipment. Our agents can compare all available Medicare Supplement Plans in your area, including all the plans that cover CPAP machines. They will provide you with quotes within minutes, and help sign you up for the plan that fits your budget and coverage needs. To get started, enter your zip code in the bar above, or to speak directly to an agent, call 888-753-7207.
