October 18th 2023
By Ari Parker
Diagnosis and treatment of sleep apnea is important. Explore coverage for sleep studies, CPAP machines, and the HNS devices, like the Inspire sleep implant
Sleep apnea is common among adults, and its prevalence increases as we age. If left untreated, sleep apnea can negatively affect the quality of sleep you receive, causing daytime sleepiness. As you know, lack of quality sleep can also affect your mood and exercise levels, so it’s important to understand what causes sleep apnea and how to treat it to live a fuller life!
In this guide, we’ll share information on what sleep apnea is, how to diagnose and treat it, and how Medicare covers services and devices for diagnosis and treatment.
Sleep apnea diagnosis and treatment is important to ensure proper breathing and oxygen levels during sleep.
Sleep apnea is diagnosed through a sleep study and most commonly treated with CPAP therapy using an at-home CPAP machine.
For moderate to severe sleep apnea, hypoglossal nerve stimulation (HNS) devices may be implanted.
Medicare covers sleep studies, CPAP machines, and HNS devices, like the Inspire implant for beneficiaries who meet the qualifications.
Medicare beneficiaries are generally responsible for 20% of the costs of services and devices used to treat sleep apnea, but costs can vary if you’re enrolled in a Medigap or Medicare Advantage plan.
Sleep apnea is a potentially dangerous condition that causes people to stop and restart breathing while they’re sleeping. There are two types of sleep apnea: obstructive and central. Obstructive sleep apnea (OSA) is the most common type of sleep apnea. It occurs when your upper area is blocked, reducing or completely stopping airflow. OSA is more common among men. The risk of OSA also increases with age and weight gain. Central sleep apnea is less common. It occurs when your brain doesn’t send signals needed to breathe.
Because obstructive sleep apnea is much more common, it’s what we’ll refer to for the rest of this article.
The main symptom of sleep apnea is breathing that stops, then starts while you’re sleeping—but this symptom isn’t always the easiest to observe. Many people find out they have sleep apnea because of complaints about snoring from their partner that cause them to seek out a sleep study. Daytime sleepiness is another common symptom that leads people to seek treatment from their doctor. Other symptoms include:
Gasping for air during sleep
Dry mouth and headaches
Sexual dysfunction or decreased libido
Waking up often during the night to urinate
We mentioned that the chances of developing sleep apnea increase with age. This is because, as we age, fatty tissue can build up in our necks and tongues, increasing the likelihood of blockage to the airway while sleeping. For this same reason, weight gain and obesity can also lead to the development of sleep apnea. Other factors that can increase the risk of sleep apnea include:
Endocrine disorders and changes to hormone levels
Family history and genetics
Heart or kidney failure
Large tonsils or a thick neck
Lifestyle habits, like drinking alcohol and smoking
Your sex: men are more likely to have sleep apnea
Sleep diaries and tracking your symptoms and risk factors can help your doctor determine if you should undergo a sleep study for official diagnosis of sleep apnea.
Given that sleep apnea is common, and prevalence increases with age, it’s important to understand how Medicare covers sleep apnea services and devices. Medicare does provide coverage for services and devices, but beneficiaries are responsible for coinsurance (which is 20% of costs with Original Medicare), and there are some requirements to ensure coverage is applied.
Medigap and Medicare Advantage plans can change how much healthcare services cost. If you have a Medigap plan, then your costs will be reduced according to your plan’s coverage. In the case of Medigap Plan G, once you’ve met your annual Part B deductible, you’d owe nothing else for Medicare-covered services.
With a Medicare Advantage plan, your costs may or may not be reduced. Each Medicare Advantage plan varies, so it’s important to look at what your cost structure is to understand what you’ll owe. If you’re not sure how to check, our team of Medicare Advisors and Advocates can help (give us a call at (855) 900-2427 for assistance), or you can discuss your costs with your doctor’s billing department.
Original Medicare does cover sleep studies. If your doctor accepts Medicare assignment, then, once you’ve met your Part B deductible, you’ll owe 20% of the Medicare-approved amount.
It’s important to discuss what your sleep study will cost with your doctor before moving forward with the service because there are a handful of factors that can affect what you pay:
Whether or not your doctor accepts Medicare assignment
The type of facility in which your sleep study takes place
How much your doctor charges
Any other insurance you have in addition to (or to replace) Original Medicare
Continuous Positive Airway Pressure devices (commonly called CPAP machines) are covered by Medicare, but it’s important to understand the specifics.
Medicare covers an initial 3-month trial of at-home CPAP therapy (including devices and accessories) for those diagnosed with sleep apnea. Once the trial is finished, beneficiaries need to meet with their doctor and receive documentation that they meet the necessary criteria and that the CPAP therapy is helping. This allows Medicare beneficiaries to continue to receive coverage for CPAP therapy.
For those who had a CPAP machine before they enrolled in Medicare, a rental or replacement CPAP machine will be covered if you meet certain criteria.
Like with most Medicare-covered services, if you have Original Medicare only, you’ll be responsible for 20% of the costs for CPAP machines once you’ve met your Part B deductible. It’s important to note: Medicare will only cover the cost of your CPAP machine (which is considered durable medical equipment, or DME) if your doctors and suppliers are enrolled in Medicare and accept Medicare assignment. So, before you choose to purchase your CPAP machine, check with the provider to confirm what you will need to pay.
According to both the Inspire website and Medicare.gov, the Inspire implant is covered by Medicare for those who meet specific criteria. The Inspire® II Upper Airway Stimulator, commonly called the Inspire implant for sleep apnea is a hypoglossal nerve stimulation (HNS) device. HNS is covered under Medicare if it’s considered a reasonable and necessary treatment for obstructive sleep apnea when the specific criteria are met.
If you have Original Medicare only, then you’ll be responsible for 20% of the costs of the Inspire sleep implant once you’ve met your annual Part B deductible. If you have a Medigap plan, then your costs may be reduced. With Medicare Advantage plans, cost structures vary, so it’s important to review your plan benefits with your doctor to determine what your costs will be.
Proper diagnosis and treatment of sleep apnea is crucial for getting quality sleep that helps us maintain our mood and energy levels. If you’re not sure how your specific Medicare insurance covers sleep apnea or want to see if another Medicare insurance option would grant you better coverage, our Medicare Advisors are here to help! We provide free, unbiased guidance to help you choose the right coverage for your needs and navigate the details of your plan. Give us a call at (855) 900-2427 or schedule a time to chat with an Advisor here to get all of your Medicare questions answered.
