What to Know About Medicare and CPAP Machines

• A continuous positive airway pressure (CPAP) machine is a breathing device used to treat obstructive sleep apnea.
• Medicare covers CPAP machines and replacement supplies as durable medical equipment (DME) under Medicare Part B (medical insurance).
• Medicare Advantage plans will also cover CPAP machines and replacement supplies if the patient has been diagnosed with obstructive sleep apnea.

A continuous positive airway pressure (CPAP) machine is a breathing device most commonly used to treat obstructive sleep apnea. It helps provide individuals with a steady flow of oxygen and air pressure into the nose and mouth during sleep.

The risk of developing sleep apnea increases with age. Since most Americans become eligible for Medicare at age 65, sleep apnea may be a health concern. Does Medicare cover CPAP machines, however?

In short, yes, the Medicare program includes coverage for CPAP therapy, including a CPAP machine rental and CPAP supplies. That said, there are rules in place in order for Medicare patients to qualify for CPAP coverage.

This article will explain everything Medicare beneficiaries need to know about Medicare and CPAP machines.
 

Sleep apnea is a common sleep disorder that occurs when the body starts and restarts breathing throughout the course of sleep. In turn, the body may not receive enough oxygen as a result. 

There are two types of sleep apnea: obstructive sleep apnea and central sleep apnea.

Central sleep apnea is a sleep disorder that happens when the brain doesn’t send signals necessary for breathing during sleep. Central sleep apnea is caused by certain health conditions that impact how the brain controls your airway and chest muscles.

Obstructive sleep apnea (OSA) is a respiratory system disorder in which the airway in the back of the throat is blocked physically. This blockage, known as an obstruction, causes temporary lapses in breathing. In some cases, a person may develop severe obstructive sleep apnea, which occurs when there are over 30 breathing interruptions per hour of sleep.

What Are The Symptoms of OSA?

Symptoms of OSA include:

• Loud snoring
• Frequently waking up
• Nocturnal restlessness
• Vivid nightmares
• Excessive daytime sleepiness
• Morning headaches
• Mood changes
• Trouble focusing

Who Is At Risk for Developing OSA?

There are a number of risk factors associated with developing OSA. These include:

• Obesity
• Being male
• Older age
• Large neck size
• Upper airway and facial abnormalities
• Family history of sleep apnea, snoring, or breathing issues
• Smoking
• Nasal congestion

What Are The Complications Associated With OSA?

Complications associated with OSA include:

• Poor sleep quality
• High blood pressure or heart problems
• Type 2 diabetes
• Liver problems
• Metabolic syndrome

How Is OSA Diagnosed?

OSA is typically diagnosed via an overnight sleep study. Sleep studies are able to diagnose the type of sleep apnea one is experiencing as well as the sleep disorder’s severity.

How Is Sleep Apnea Treated?

Sleep apnea is treated through interventions such as wearing breathing devices while sleeping and lifestyle changes such as losing weight, limiting alcohol intake, getting regular exercise, and more.

CPAP stands for continuous positive airway pressure. A CPAP machine is a breathing apparatus that gives individuals a steady flow of air into the nose and mouth while they sleep.

CPAP machines are usually prescribed to treat sleep apnea disorders, most commonly OSA.

Benefits Of Using A CPAP Machine

There are a number of benefits to using a CPAP machine.

• Better sleep

• Heart disease prevention

• Improved emotional stability

• Reduced medical expenses

• Eliminated snoring

• Enhanced concentration

A CPAP machine usually costs between $400-$1200, depending on the quality of the machine. In addition to the machine, other costs may include paying for CPAP supplies such as:

• Humidifier

• Masks

• Hose

• Replacement CPAP supplies (e.g., filters)

Medicare coverage includes CPAP machines. That said, a Medicare beneficiary must meet a number of criteria in order for the CPAP machine to be covered by Medicare.

This criteria includes:

• Undergoing a sleep test (either in a lab setting or by using an approved at-home test)
• Receiving an OSA diagnosis based on the sleep study results
• Obtaining a prescription for the CPAP machine from the patient’s doctor
• Getting the CPAP machine via a Medicare-approved supplier

How Does Medicare Cover CPAP Machines?

As a reminder, Medicare functions in two main parts. These Medicare Parts are Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). CPAP machines would fall under Medicare Part B coverage.

Does Medicare Cover CPAP Supplies?

Under Medicare Part B, along with CPAP machines, CPAP supplies are also usually covered for the same amount of time.

These supplies can include:

• Face mask
• Tubing
• Filters

Understanding Medicare Part B Coverage

Under Medicare Part B, Medicare beneficiaries pay 20% of the Medicare-approved amount for the rental of the CPAP machine and associated CPAP equipment. The Medicare Part B deductible applies. 

At first, Medicare will only cover a three-month trial period of CPAP therapy. That said, Medicare may pay for CPAP therapy longer with proper documentation from a Medicare beneficiary’s doctor. If the patient’s doctor says the CPAP therapy is working, Medicare will cover the CPAP treatment.

Medicare pays the CPAP machine supplier during the rental period of the device. Medicare will cover up to 13 months of CPAP rental. After that 13-month period, a beneficiary will then own the CPAP device. Do note, the supplier must be enrolled in Medicare in order for Medicare to cover the CPAP machine and associated supplies.

Medicare Advantage plans, also known as Medicare Part C or MA plans, are supplemental Medicare plans. Medicare Advantage plans bundle Medicare Part A and Medicare Part B into one health insurance plan. MA plans are offered through private insurance companies that are Medicare-approved.

A Medicare Advantage plan will also often have additional benefits, including dental, hearing, and vision. MA plans also often include Medicare Part D, prescription drug coverage, within its policies.

Because MA plans have both Medicare Part A and B combined in one plan, coverage for CPAP machines will work in the same way as Original Medicare.

Medigap is Medicare’s supplemental insurance. Medigap provides additional coverage for Medicare beneficiaries. Medigap plans help ​“fill in the gaps” of Original Medicare.

Medigap may help pay some of the costs for a CPAP machine. For example, many Medigap policies are sold by private insurance companies and help pay some out-of-pocket costs such as deductibles, coinsurance, and copays. This may include covering the Part B deductible amount.

Do note, someone cannot be enrolled in both a Medicare Advantage plan and a Medigap plan, as they’re both considered supplemental insurance to Medicare.

In order to find a Medicare-approved supplier for a CPAP machine, visit the official Medicare website’s DME supplier search tool.