Sleep apnea is a sleep disorder in which people stop breathing for periods of time during sleep. When sleep apnea is left untreated, it can cause other serious issues such as heart disease, stroke, diabetes, high blood pressure, and more. It can also cause metabolic problems and the risk of accidents due to sleeplessness. CPAP (continuous positive airway pressure) therapy is a type of treatment for people with sleep apnea. Medicare pays for some of the costs associated with using a CPAP machine under its coverage of durable medical equipment when certain eligibility requirements are met. Let’s take a closer look at the details of whether Medicare covers CPAP machines.
Eligibility for Medicare to cover CPAP machines
Medicare will cover CPAP therapy for a three-month trial period after you’ve completed a sleep test, met with your doctor in person, and your doctor has diagnosed you with sleep apnea. The three-month period will inform the doctor if the therapy is helping you and whether you are using it as you should. If the machine doesn’t produce good results, the doctor may prescribe a different machine or therapy.
Your sleep doctor must prescribe a CPAP machine, and you must obtain a CPAP machine from a supplier that accepts Medicare as payment. Your doctor must also document in your medical record that the CPAP therapy is helping you. As for your responsibility, you must agree to use the CPAP machine regularly.
After you’ve met your Part B deductible, Medicare will cover 80% of the costs of renting the machine and purchasing the accessories, such as hoses, filters, headsets, masks, and water tanks.
If you already own a CPAP machine and switch to Medicare, your Medicare plan will cover a rental machine or replacement as long as you meet certain requirements (e.g., meeting with your doctor in person, seeing a doctor who accepts Medicare, using a participating Medicare supplier, etc.).
Renting vs. buying a CPAP machine
Some individuals choose to purchase CPAP machines outright but must do so out of pocket, as Medicare does not cover the total purchase cost. The average cost of buying a CPAP machine is $649 to $989, according to the National Council on Aging.
Other people choose to rent their machines. After the three-month trial period of using a CPAP machine, Medicare will pay for 80% of the rental for the next 13 months. Once you’ve rented a machine for 13 months, you own it.
The lifetime expectancy of a CPAP machine is about five years. For that reason, Medicare will cover a new CPAP machine once your machine is five years old. If your machine breaks before the five years are up, they will cover the repair or replacement cost.
Costs
Before original Medicare will pay for your CPAP machine, you must meet your Medicare Part B deductible. After you’ve satisfied your deductible, you will be responsible for 20% of the rental cost, and Medicare will pay the rest. Medicare also pays 80% for your sleep therapy doctor visits (after your deductible) and a sleep test when you have sleep apnea symptoms. Coverage under Medicare Advantage varies based on the details of your plan.
Those who are dually enrolled in Medicaid and Medicare or have a Medigap plan may be able to get help with some of the out-of-pocket costs associated with CPAP therapy. You may also find used or refurbished equipment for sale at a reasonable price online.
Be aware that if the supplier doesn’t accept Medicare, you may have to pay for the machine and accessories out of pocket.
Replacement parts, accessories, and other expenses
The cost of a CPAP machine is one consideration, but there are ongoing expenses for accessories and equipment care. Headsets, hoses, and masks can lose effectiveness over time if they are not replaced at the recommended intervals. As with the machine costs, Medicare will pay 80% of the cost of replacement parts and accessories necessary to use the machine, such as tubes, masks, and air filters, all of which must be replaced regularly.
Medicare will also cover repairing or replacing the machine due to normal wear and tear as long as it isn’t under warranty. Your doctor must certify that the repair is medically necessary before Medicare will cover the cost.
Your doctor will continue to monitor your breathing while you sleep. If your results are not good, they may prescribe you a different type of CPAP machine. Medicare will cover the costs of a different machine if your doctor deems it medically necessary. The plan will pay for the new machine at the same rate as before.
Navigating the details of when Medicare covers CPAP machines
We’ve highlighted the basics of Medicare coverage for CPAP therapy and the necessary equipment for treating sleep apnea. Still, it’s essential to ask your doctor why they recommend a particular machine and how long you may need it. Be sure to ask your physician’s office how much your costs will be and under what circumstances Medicare will cover a portion of the bill. Remember that your doctor and health insurance plan are partnering with you to improve your health, so using your machine and taking care of it as your doctor instructs you to is critical.
