Does Medicare Cover CPAP Machines?
If you find yourself tired during the day, moody, sleeping erratically, or keeping your partner awake at night because you’re snoring, you may suffer from sleep apnea.
A simple sleep test can confirm this. If you are diagnosed with sleep apnea, your doctor may recommend that you use a CPAP machine. Original Medicare and most other insurance plans cover CPAPs because they’re considered medically necessary.
The American Academy of Sleep Medicine estimates that over 25 million American adults have been diagnosed with sleep apnea. However, it’s expected that many more people live with undiagnosed sleep apnea. The dangers of this condition go far beyond daytime sleepiness. Sleep apnea increases the risk of high blood pressure, heart disease, type 2 diabetes, strokes, and depression. Those who are older or obese are the most likely to develop sleep apnea.
Fortunately, CPAP therapy can help reduce all sleep apnea symptoms and reduce other health risks. Read on to learn more about CPAP machines, including how Medicare covers them.
Key Takeaways:
Medicare covers CPAP machines if you do a sleep study and get a prescription from a doctor.
Part B covers CPAP machine, which means Medicare pays 80% of the cost once you’ve met your Part B deductible.
Medicare will cover a replacement CPAP machine once every five years.
Medicare Advantage plans must offer at least the same coverage, but costs, copays, and supplier rules vary by plan.
What is a CPAP machine?
A CPAP (continuous positive airway pressure) machine is a medical device used to treat obstructive sleep apnea. It delivers a steady stream of air through a mask, keeping your airways open during sleep.
What is obstructive sleep apnea?
Obstructive sleep apnea (OSA) is a common sleep disorder that causes your breathing to repeatedly pause during sleep.
Here's a breakdown of what happens when you have sleep apnea. First, your airway is obstructed. As you sleep, the muscles that support the soft tissues in your throat, such as your tongue and soft palate, relax. If you have OSA, this relaxation leads to a narrowing or blockage of the airway that disrupts the flow of air to the lungs.
As a result, you experience pauses in your breathing called “apneas,” which can occur many times throughout the night. Each time your breathing is interrupted, your brain briefly wakes you from sleep to restart your breathing. These awakenings are often so brief, you don't remember them—but they do cause sleepiness the next day.
How does the machine work?
A CPAP machine provides a consistent amount of pressure to your airways that keeps the airways open. Most models have a ramp-up feature that starts at low pressure, helps you fall asleep, and increases while you sleep. CPAP machines available in a range of sizes, including a smaller portable size for travel.
To use the machine, you wear a face mask that connects to the CPAP device with tubing to deliver air. There are three basic types of masks:
Oronasal masks that cover both your nose and mouth are good for those who breathe through the mouth at night.
Nasal masks attach from the upper lip to the nose to deliver pressurized air through your nose.
Nasal pillows are flexible silicone prongs that create a seal at the level of your nostrils.
You may need to experiment to find the most comfortable and effective mask for you.
Does Medicare cover CPAP machines for sleep apnea?
Medicare covers CPAP machines and any necessary accessories, like a mask, for the treatment of obstructive sleep apnea.
Medicare Advantage (Part C) plans must cover at least the same services and equipment as Original Medicare. However, Medicare Advantage plan deductibles and copays are different from Original Medicare and also differ between plans.
What are the Medicare requirements for CPAP machine coverage?
If you have sleep apnea, a CPAP machine can help you sleep better. Medicare covers CPAP machines if you meet the following eligibility requirements:
You’ve completed a sleep study and received a diagnosis of OSA from a doctor.
The prescribing doctor and the DME equipment supplier both participate in Medicare.
It’s important to note that CPAP machines fall under Part B, meaning you must meet the part B deductible before Medicare will cover costs. After meeting your deductible, you are still responsible for 20% of the cost, unless you have a Medicare Supplement plan.
Initially, Medicare will typically cover a 3-month trial period to ensure that the CPAP is effective. Continued coverage after the initial rental period is based on whether the machine is being used and whether it is effective.
To continue receiving coverage:
You must use the CPAP machine for specific hours each night.
Your doctor must document in your medical record that you're benefiting from CPAP treatment.
You must have proof that you've received education from the CPAP provider on properly using the machine.
How much does a CPAP cost?
The price range for a CPAP machine is usually between $600 and $1,000, though it could cost more. More costly machines come with more features and include more accessories.
CPAP machines are one of the most cost-effective solutions for better sleep if you have sleep apnea.
Two popular alternatives are much more expensive:
BiPAP (Bilevel Positive Airway Pressure) machines push out two different air pressures when you inhale and exhale. They usually cost between $1,700 and $3,000.
APAP (Auto-Adjusting Positive Airway Pressure) machines are more technologically advanced as they automatically adjust the amount of pressure if breathing slows or stops. They usually cost $600 to $1,600.
How much does Medicare pay for a CPAP machine?
Medicare Part B helps cover the cost of CPAP machines for people diagnosed with obstructive sleep apnea, but payment works a little differently than a simple purchase.
After you have a sleep study and get a prescription, Medicare typically rents the CPAP machine to you for 13 months. During this period, once you’ve met your Part B deductible, Medicare pays 80% of the Medicare-approved amount, and you pay the remaining 20%. If you continue using the machine as required, you’ll own the machine after those 13 continuous rental months.
Accessories like masks, tubing, and humidifier chambers are also covered on a replacement schedule, with Medicare again paying 80% of the approved cost. Using a Medicare-approved supplier is important because choosing one that accepts “assignment” ensures you’re only responsible for your expected share instead of potentially higher charges.
Medicare Advantage plans also cover CPAP equipment, though their rules, suppliers, and copays may vary. Overall, most users end up paying a modest portion of the equipment cost while Medicare covers the bulk of it.
How often will Medicare pay for a new CPAP machine?
Medicare covers a new CPAP machine once every five years. If you need a new one before that, you will have to pay for it yourself.
Below are a few ways you can lower your out-of-pocket costs:
Rent a CPAP machine for $29 to $69 a month (plus a deposit for the device).
Buy a refurbished machine at a discount from a used CPAP retailer, such as SecondWindCPAP. Buying from a retailer is better than buying one from Facebook Marketplace or eBay, as the machines have been tested and reconditioned.
Sign up for discounts through the American Sleep Apnea Association's CPAP machine and mask assistance programs.
Does Original Medicare cover CPAP supplies?
Using a CPAP machine requires a continuous flow of supplies. Medicare covers replacement supplies, including masks, filters, tubes, and humidifiers, under Medicare Part B. Medicare will cover 80% of the cost once your Part B deductible is met, and you are responsible for the other 20%. That said, if you have a Medicare Supplement plan, your out-of-pocket costs will be lower.
How much does Medicare Advantage pay for a CPAP machine?
Medicare Advantage plans are offered by private insurance companies. Each Medicare Advantage plan is different. As such, your cost for a CPAP machine will depend on your specific Medicare Advantage plan.
If you have questions about your coverage, call your plan's customer service number to ask about:
Coverage requirements
Prior authorization procedures
Preferred suppliers
Your out-of-pocket cost