However, this form of therapy doesn’t cure sleep apnea, so you may continue to use a CPAP machine indefinitely. This continuous use may require you to occasionally replace some CPAP supplies, which could be a recurring expense. Learn what type of Medicare coverage pays for CPAP machines, when it will cover CPAP machines and supplies, and what costs you may need to pay out of pocket.
When Will Medicare Cover CPAP Machines?
Medicare Part B covers the use of CPAP machines by adult patients with obstructive sleep apnea. Medicare initially will cover the cost of the CPAP for up to three months if your sleep apnea diagnosis is documented by a sleep study. Medicare will cover the sleep apnea machine after the initial three-month trial period if your doctor—after meeting you—documents in your medical record that you meet certain conditions about using the device and that you benefited from CPAP during the initial trial period. Upon completion of the trial period, you must be re-evaluated to determine whether there is a medical necessity to warrant Medicare coverage of the CPAP machine beyond those initial three months. Medicare won’t continue coverage for subsequent months without this re-evaluation.
How To Get Medicare To Cover a CPAP Machine
Medicare will cover a CPAP machine if you meet two conditions. You must first be diagnosed with obstructive sleep apnea, and you must submit your primary doctor’s order or prescription to the right supplier to receive coverage. Here are the steps you’ll need to take to make that happen.
Get an Initial Clinical Evaluation
For Medicare to cover a CPAP machine, you must first have a face-to-face evaluation with your primary care physician to assess you for obstructive sleep apnea. You’ll then take a sleep test that your doctor will use to document in your medical record symptoms of sleep apnea. If you have sleep apnea, Medicare may cover your CPAP machine for an initial three-month trial period.
Get a Second Clinical Evaluation
If Medicare covers your CPAP machine for the three-month trial period, you must undergo a second clinical evaluation to establish medical necessity for continued coverage. During the face-to-face evaluation, your doctor must document that your symptoms of sleep apnea have improved and that you’ve adhered to consistent CPAP therapy.
Submit an Order to the Right Supplier
In order to obtain a CPAP machine, your primary care doctor must sign an order or prescription stating that it is medically necessary to help with sleep apnea. Medicare will only cover your durable medical equipment (DME) if the supplier your order is sent to is enrolled in Medicare.
Owning the DME
Depending on the DME, you may have the option to either rent or buy it. Most equipment is initially rented and Original Medicare will pay 80% of the monthly rental fee for 13 months. You’ll pay the remaining 20%. After 13 months, you will own the machine.
How Much Does a CPAP Machine Cost With Medicare?
Medicare typically covers the most basic level of equipment, and it may not pay for upgrades. In the case where Medicare doesn’t cover upgrades or extra features, you’ll need to sign an Advance Beneficiary Notice (ABN) before you get the equipment. Your out-of-pocket cost for renting a CPAP machine and buying related supplies like masks and tubing is 20% of the Medicare-approved amount. The Part B deductible applies. In addition, you must consistently use the CPAP machine for 13 months in order for Medicare to cover the cost of renting it. After 13 months, you will fully own the machine. Medicare Advantage Plans set their own rates for DME coverage. Your plan may require you to secure approval before making an order, order from in-network providers, or use preferred DME brands. Your plan may reduce or deny coverage for the DME if you don’t follow these rules.
The Bottom Line
The rules of how DMEs are covered, including CPAP machines, are generally the same whether you have Original Medicare or a Medicare Advantage Plan. However, the amount you pay with Original Medicare and a Medicare Advantage Plan may often differ. Compare Medicare and Medicare Advantage to learn more. Medicare also covers specific prescription medications and supplies used with a DME, even if they’re disposable or can only be used once. Medicare will only cover your CPAP machine if you get it from a supplier approved by Medicare and holds a Medicare supplier number.
