Medicare Part B covers CPAP machines as durable medical equipment.
A continuous positive airway pressure (CPAP) machine helps treat sleep apnea disorders. These devices apply a constant level of pressure to the upper respiratory tract, which prevents the collapse of your airway and makes it easier to breathe while sleeping.
While a CPAP isn’t necessarily right for everyone, it can help make sleeping and breathing easier. But these machines, as well as part replacement and maintenance, are expensive. The good news is CPAPs are considered durable medical equipment (DME), and Original Medicare insurance will cover a CPAP if you meet certain conditions.
How does a CPAP work?
A continuous positive airway pressure machine sends a steady flow of pressurized air into your nose and mouth while you sleep. This helps keep your airways open so you can breathe normally. The machine’s compressor generates this stream of air, which travels through an air filter into a tube. The tube delivers the air to a mask that seals around your nose or mouth.
Components of a CPAP machine include:
- Base unit with a motor
- Tube connecting the motor to the mask
- Headgear frame
- Pieces that act as joints to connect parts
- Adjustable straps
There are also different mask styles depending on your breathing habits, mask comfort, and the type of sleep apnea you have. For example, your doctor may recommend a nasal pillow mask, a nasal mask, or a full-face mask.
Does Medicare cover CPAP machines?
Medicare Part B may cover a three-month trial period of CPAP therapy for beneficiaries who have been diagnosed with obstructive sleep apnea. After this trial period, CPAP therapy will continue to be covered if:
- You continue to meet with your doctor in person
- Your doctor documents in your medical record that you meet certain conditions, and the therapy is helping you
- You have a prescription for your CPAP machine (in some cases)
If you had a CPAP device before you got Medicare and if you meet certain requirements, Medicare may cover a machine rental or replacement CPAP device, CPAP equipment, or replacement supplies. Medicare will pay the DME supplier to rent a CPAP machine for 13 months if you’ve been using it without interruption, and after rental payments are made for 13 continuous months, you’ll own the machine.
It’s important to note that while Medicare coverage includes CPAP machines, CPAP cleaning machines and sanitizing solutions are not considered “medically necessary” by Medicare and therefore not covered. You would pay for 100% of the cost out-of-pocket.
Medicare Advantage CPAP coverage
Medicare Advantage plans (Part C) cover everything Part A and Part B do, and more. Because they are offered by private insurance companies who contract with Medicare, most offer additional benefits like Part D prescription drug coverage, dental, vision, hearing, and other services.
Since Medicare covers CPAP machines and related equipment, Part C plans do as well if it’s considered medically necessary. Check with your plan for any restrictions and to learn more about the cost.
Does Medigap cover CPAP devices?
Medicare Supplement plans, also known as Medigap, are sold by private insurance companies and can help pay some of the healthcare costs Original Medicare doesn’t cover. This may include deductibles, co-pays, and co-insurance costs depending on which Medigap plan you choose.
Because Medicare does cover CPAP machines, Medigap plans can also help further offset those costs, helping to pay for the machine, machine rental, or other CPAP supplies.
How much does a CPAP cost?
If you CPAP is covered, you’ll pay 20% of the Medicare-approved amount for the rental or purchase of the machine, as well as purchase of any related supplies (like masks and tubing). Note that you may have to pay the entire bill (both your and Medicare’s share) at the time you get the DME, but your supplier will submit for reimbursement.
The Part B deductible does apply.
It is very important to choose a durable medical equipment supplier who both accepts assignment and participates in Medicare. If the DME supplier does not accept assignment, there is no limit on the amount they can charge you. You would be responsible for paying that cost out-of-pocket, so it’s important to choose an enrolled supplier.
Additionally, if you choose to purchase equipment like CPAP cleaning machines and/or sanitizing solutions, they are not covered by Medicare so you would pay 100% of the cost.
How to find a durable medical equipment supplier
Medicare Part B covers medically necessary DME if it’s prescribed by your doctor and the doctor and supplier are enrolled in Medicare. To find a medical supplier enrolled in Medicare, you can use this free, online tool from Medicare.gov.
Simply enter your zip code and the equipment you’re looking for (CPAP), and a list of covered suppliers in your area will populate. You can sort by distance from you or supplier name. You can also compare multiple suppliers side-by-side.
When is a CPAP necessary?
A CPAP helps those with obstructive sleep apnea, which is the most common sleep-related breathing disorder. This disorder causes you to stop and start breathing repeatedly while you sleep. A CPAP can help keep your airway open while you sleep, which can reduce how much you start and stop breathing.
You may need a CPAP if you have symptoms such as:
- Excessive daytime sleepiness, causing you to fall asleep while doing daily activities, working, or even driving
- Loud snoring that is enough to disturb your sleep or the sleep of others
- Episodes of stopped breathing while sleeping
- Waking up gasping or choking
- Waking up with a dry mouth or sore throat
- Mood changes or difficulty concentrating
- High blood pressure
- Decreased libido
Poor sleep can have a significant impact on your health, so if you’re experiencing any of the above, you should talk to your doctor about whether a CPAP is right for you. There are different types of sleep apnea, so you may have to participate in a sleep study, sleep test, or other testing to confirm a diagnosis and best treatment options.
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