CPAP, short for continuous positive airway pressure, is a widely prescribed therapy for OSA. Medicare, the federal health insurance program primarily for people aged 65 and older, offers coverage for these machines as part of its durable medical equipment benefit.

Getting Medicare CPAP coverage is relatively straightforward, and we will explore the options and Medicare rules for CPAP machines, helping you understand whether this vital equipment is included in your Medicare benefits.

Does Medicare pay for CPAP machines?

Yes, Medicare does pay for CPAP machines. Medicare provides coverage for CPAP machines as part of its durable medical equipment benefit.

If you’ve been diagnosed with obstructive sleep apnea, Medicare may cover a 3-month trial of CPAP therapy, including the machine and accessories.

After the trial period, Medicare may continue to cover CPAP therapy, devices, and accessories if certain conditions are met, and your doctor confirms the therapy’s effectiveness.

Medicare Part B CPAP supplies coverage

If you have been prescribed CPAP therapy for obstructive sleep apnea, Medicare Part B can help cover the costs of essential CPAP supplies like masks, tubing, filters, and other necessary accessories. 

After meeting the Part B deductible, you typically pay 20% of the Medicare-approved CPAP machines amount. At first, Medicare will cover a three-month trial period of CPAP therapy. If your doctor confirms that the therapy is working, Medicare may cover it longer.

During the rental period, Medicare takes care of the payments to the CPAP machine supplier. You get up to 13 months of rental coverage; after that, you become the proud owner of the CPAP device. It’s important to ensure that your doctors and suppliers are enrolled in Medicare to receive coverage for Medicare CPAP supplies. 

So, if you’re relying on CPAP therapy and wondering if Medicare Part B will cover the supplies, the answer is yes!

Do Medicare Advantage plans cover CPAP machines?

Yes, Medicare Advantage plans will cover CPAP machines if the patient has been diagnosed with obstructive sleep apnea. Medicare Advantage plans, also known as Medicare Part C, are offered by private insurance companies approved by Medicare. 

These plans are required to provide at least the same coverage as Original Medicare (Medicare Part A and Part B). Since Original Medicare covers CPAP machines as durable medical equipment (DME), many Medicare Advantage plans also include coverage for CPAP machines.

However, the specific coverage and costs can vary depending on the plan. It’s important to review the details of your Medicare Advantage plan, including the coverage and any potential out-of-pocket expenses associated with CPAP machines. 

You can contact your plan provider or review the plan documents to get more information on CPAP coverage under your Medicare Advantage plan.

Types of CPAP machines covered by Medicare

The specific types of CPAP machines covered can include:

• Standard CPAP machines: Deliver a continuous fixed pressure to keep the airway open during sleep
• APAP (Auto-Adjusting Positive Airway Pressure) machines: APAP machines are designed to automatically adjust the pressure based on the individual’s breathing patterns, providing customized therapy. 
• BiPAP (Bi-Level Positive Airway Pressure) machines: BiPAP machines offer different pressure levels for inhalation and exhalation, beneficial for individuals who require higher pressure support.

It’s essential to consult with your doctor to determine which type of CPAP Medicare machine is most suitable for your specific sleep apnea condition. By working with your healthcare provider, you can ensure that the CPAP machine prescribed meets Medicare’s coverage criteria and provides effective treatment for your sleep apnea.

How often can I get a new CPAP machine on Medicare?

In 2024, Medicare has a replacement schedule for CPAP supplies to ensure beneficiaries have access to necessary equipment. Here’s an overview:

• CPAP machine: After renting CPAP Machines covered by Medicare for 13 months, Medicare allows you to own the device. Once you own it, Medicare will no longer cover a replacement machine unless the existing one becomes unusable or requires repairs that are not cost-effective.

• CPAP supplies: Medicare provides coverage for replacement CPAP supplies regularly. Generally, Medicare allows replacement supplies like masks, tubing, and filters to be provided every three months. However, the specific replacement schedule may vary depending on the supplier and individual circumstances. It’s important to work with a supplier enrolled in Medicare to ensure coverage for CPAP supplies and adhere to Medicare CPAP guidelines.

Medicare guidelines for CPAP replacement

Medicare has specific guidelines for CPAP replacement based on whether they paid for your previous device or not. Let’s break it down:

Medicare paid for your last device

If Medicare covered your previous CPAP device, visit your doctor and discuss your obstructive sleep apnea (OSA) and CPAP usage since obtaining Medicare. Ask your doctor to provide the following:

• Prescription for a replacement CPAP device.
• Medical records containing information about your OSA, CPAP usage history, and the condition of your current CPAP device, confirming its benefits. Medicare will pay for a replacement CPAP device if it is lost, stolen, irreparably damaged due to a specific incident, or if it is older than 5 years and no longer functioning properly. Your medical records and sleep study results must meet Medicare’s documentation requirements and current coverage criteria for reimbursement.

Medicare did not pay for your last device

If Medicare did not cover your previous CPAP device, consult your doctor regarding your OSA and CPAP usage since obtaining Medicare and request the following from your doctor:

• Prescription for a replacement CPAP device.
• Medical records from a doctor’s visit since having Medicare containing information about your OSA, CPAP usage history, and the condition of your current CPAP device.
• Your most recent sleep study results. Medicare will pay for a replacement CPAP device under the same conditions as mentioned above (lost, stolen, irreparably damaged, or older than 5 years). Your medical documentation and sleep study results must meet Medicare’s documentation requirements and current coverage criteria.

Medicare CPAP documentation requirements

Regarding Medicare coverage for CPAP devices, certain documentation requirements must be met. Here are the Medicare CPAP documentation requirements:

1. Diagnosis of Obstructive Sleep Apnea (OSA)

Your medical records should include a confirmed diagnosis of OSA, a serious condition that disrupts sleep and increases the risk of various health issues such as cardiovascular disease, diabetes, and depression.

2. CPAP usage confirmation

The medical records must indicate that you have been using the CPAP device and benefiting from its use. This shows that the therapy is effective in treating your sleep apnea.

3. Prescription for CPAP device

A prescription from your doctor stating the need for a CPAP device is essential. This confirms that the device is medically necessary to treat your OSA.

4. Sleep study results

Your medical records should include recent sleep study results. These results provide objective evidence of your sleep apnea condition and help determine the appropriate treatment, such as CPAP therapy.

How much does a CPAP machine cost with Medicare?

The price of a CPAP machine can vary depending on the features and brand. On average, CPAP machines range from $500 to $1,000 or more. Keep in mind that machines with advanced features may be on the higher end of the price spectrum.

Medicare covers CPAP machines as durable medical equipment. However, you will need to meet the Medicare Part B deductible, which is $240 in 2024. After meeting the deductible, you will typically pay 20% of the Medicare-approved amount for the CPAP machine rental and ongoing supply purchases.

Now, let’s do a sample calculation: Let’s say the Medicare-approved amount for a CPAP machine rental is $800. After meeting the deductible of $240, you would pay 20% of the remaining amount, which is $112 (20% of $560). This would be your share of the cost of the CPAP machine rental.

It’s important to note that these calculations are for illustrative purposes only and the actual costs may vary based on specific circumstances and Medicare-approved amounts.

Does Medicare cover CPAP cleaning machines?

While Medicare covers CPAP machines for seniors diagnosed with obstructive sleep apnea, the program does not extend its coverage to include cleaning machines.

Does Medicare cover travel CPAP machines?

In some cases, Medicare may cover a travel CPAP machine if it is deemed medically necessary and meets the coverage criteria. However, it’s important to note that Medicare typically follows a five-year replacement schedule for CPAP machines. If you have received a new CPAP machine within the past five years, Medicare may not cover a travel CPAP during that time period.

Conclusion

The good news is that Medicare covers CPAP machines for people with obstructive sleep apnea. 

It’s a relief to know that this federal health insurance program acknowledges the importance of CPAP therapy in improving sleep and overall well-being. 

You’ll need a doctor’s prescription based on a sleep study diagnosis to get coverage. Initially, Medicare typically pays for a three-month trial period, but continued coverage is possible if your doctor sees progress. 

Keep in mind, though, that Medicare may not cover extra accessories or CPAP cleaning machines.