- Medicare will cover a part of the cost of a CPAP machine if you’ve been diagnosed with obstructive sleep apnea.
- Coverage for CPAP machines falls under the Medicare Part B coverage of durable medical equipment.
- You’ll still pay a portion of the cost for your CPAP machine, unless you have a Medigap plan to cover those costs.
A continuous positive airway pressure (CPAP) machine is a medical device that gives you extra oxygen with a bit of force.
If you have obstructive sleep apnea (OSA), the CPAP machine makes sure that oxygen is being pushed into your airway to help you overcome breathing pauses or obstructions that might cause your oxygen levels to drop.
Medicare covers these machines, but you need to meet certain criteria. And even so, you’ll typically have to pay a share of the cost for your CPAP machine.
Original Medicare offers coverage for CPAP machines. Original Medicare is made up of parts A (hospital insurance) and B (medical insurance).
To have your CPAP machine covered, you need to make sure that your clinician and device supplier participate in the Medicare program. You can search for local Medicare-approved providers here and suppliers here.
You then need to be sure that you’re up-to-date in paying your Medicare Part B premiums and have met your annual deductible.
Once you’ve met this one-time deductible for the year, you’re responsible for 20 percent of the Medicare-approved amount for covered equipment.
What if I have a Medicare Advantage plan?
Medicare Advantage (Part C) plans are private insurance products that combine the services offered by original Medicare with some extras, depending on the plan.
These types of plans may offer additional coverage for medical equipment and services that fall under Medicare Part B coverage. The amount you’ll pay for these devices will depend on the plan you choose and how much you can afford to pay in monthly premiums for the added coverage.
However, some Medicare Advantage plans may place additional restrictions and conditions on the suppliers and providers you can choose based on their network.
If your doctor orders CPAP therapy for you, Medicare will cover 80 percent of the cost of the following equipment after you’ve met your deductible:
- CPAP machine rental for a 3-month trial if you’re newly diagnosed
- CPAP rental for 13 months if you’ve been using it consistently (after 13 months, you’ll own the CPAP machine)
- masks or nose pieces you wear when using the machine
- tubing to connect the mask or nose piece to the machine
This Medicare coverage applies only if your doctor and supplier participate in the Medicare program.
You may be asked to pay the entire cost up front and then be reimbursed by Medicare.
If the amount of your equipment is more than what Medicare allows or your supplier doesn’t participate in Medicare, you could have to pay more than 20 percent of the cost — even the entire amount.
Medicare has certain rules when it comes to equipment replacement for CPAP machines.
You’ll be covered for the cost of equipment that works with your CPAP machine if you’re new to Medicare and already had a CPAP machine.
Your CPAP machine is paid for after 13 months and you’ll own it, but it should last several years. You may have it replaced with your medical benefit after this time.
Other supplies are less sustainable and need more frequent replacement. Below is a list of how many times per year Medicare will pay for a portion of certain CPAP supplies, according to the Department of Health and Human Services:
- humidifier water chamber: 2 times per year
- nondisposable filters: 2 times per year
- chinstrap: 2 times per year
- headgear: 2 times per year
- CPAP tubing with heating element: 4 times per year
- combination oral/nasal CPAP mask: 4 times per year
- full face mask: 4 times per year
- nasal interface: 4 times per year
- tubing: 4 times per year
- full face mask interface: 12 times per year
- cushion for nasal mask interface: 24 times per year
- nasal pillows: 24 times per year
- disposable filter: 24 times per year
- replacement oral cushion for oral/nasal mask: 24 times per year
- replacement nasal pillows for oral/nasal mask, one pair: 24 times per year
To qualify for Medicare coverage of a CPAP machine, your doctor has to diagnose you with OSA. This often requires a sleep study. Medicare Part B covers the cost of sleep studies as well.
If you have been newly diagnosed with OSA, Medicare will cover a 3-month trial of a CPAP machine. If your doctor documents that CPAP therapy is helping your condition and writes an order for continued therapy, Medicare will keep covering your CPAP machine.
Sleep apnea is any condition that causes you to pause in your breathing while you sleep. These pauses can cause a drop in your oxygen level, leading to damaging effects on your brain, energy levels, sleep quality, respiratory system, and a number of other bodily systems.
There are three main types of sleep apnea:
- OSA. This is the most common form of sleep apnea, caused by tissues that become too relaxed and block your airway.
- Central sleep apnea. This is caused by a problem with the signals sent from your brain to the muscles that control your breathing.
- Complex sleep apnea syndrome. This is a combination of both obstructive and central sleep apnea.
OSA symptoms may include:
- loud snoring
- pauses in your breathing while you sleep
- shortness of breath or gasping for air during sleep
- headaches in the morning
- excessive daytime sleepiness
- difficulty concentrating
- dry mouth when you wake up
You may be diagnosed:
- after a hospital stay where your apnea was noticed by a healthcare professional
- by listing your symptoms to your doctor
- through a sleep study
Medicare covers sleep studies and may actually require one for long-term CPAP coverage. For your sleep study to be covered by Medicare, it must be ordered by your doctor and conducted in a sleep lab facility.
Aside from CPAP machines, treatments for obstructive sleep apnea include:
- other devices that can open the airway, such as oral appliances
- supplemental oxygen
- surgery to remove excess tissue that is obstructing your breathing
For people who struggle with sleep apnea, there are several treatment options.
If a CPAP machine is the right solution for you, you will probably need a sleep study. Both your sleep study and CPAP machine will be covered by Medicare Part B, as long as your doctor and supplier participate in Medicare.
Expect to pay a share of the costs under your Medicare Part B or Medicare Advantage plan.